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Miscellaneous - 814 OSGOOD STREET 4/30/2018 (2)
DateA..`2`/—V-/*- ..... TOWN OF NORTH ANDOVER PERMIT 'FOR WIRING This certifies that .7.?!5q .... . ............................. has permission to perform wiring in the building of .. 'j ......................... . ... ... .... at . 41 ...... ............... o Andover, Mass. Fee Lic. No. X:> ....... .......... ................ s . E 'i�E**M4'rRICAL INS E Check # 0425 X Commonwealth of Massachusetts Official 'Use Only Permit No. / C> 7 Department of Fire Services Occupancy and Fee Checked `y BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL. WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINTW INK OR TYPE ALL INFORAfATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perfoim the electrical work described below. Location (Street & Number)��– Owner or Tenant -E11�fi U . J aOoC�s C\.) Telephone No. 9 Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Erasting Service /—o Amps / / Volts Overhead– Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and.Ampacity �� ' , S ��/ t• ¢� Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Inspector of Wires. Recessed Tun nai a No: of __�-�ss _ ,__ . _ _re f C '1 Su .> ) r No. o� ..e;.. cusp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No, of Luminaires Swimming Pool Above ❑'In- -E]o. nd. rnd. o Emergency Lighting Battery Units No. of Receptacle Outlet's No. of Oil Burners FIPX ALAR.MS No. of Zones Ido. of Switches No. of Gas Burners No..of Detection and. Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices . No. of Waste Disposers Heat Pump Totals: Number -'.._ ............................... Tons KW -- .......... No, of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local [I Connection ❑Other Connection No. of Dryers 'Heating Appliances pp KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts . Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: .Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) erti under the ains and enalties o 'u that the information on this application is true and complete. �c $��C� RM NAME: P. P fJ�rJ'' ., /J PP n� P //, i LIC. NO.: 4 2no96 Licensee:J0�f, ,14, 2,LK Y1.9J 6f � Signature �✓ LIC. NO.: (If applicable, enter "exempt" in the license nu er line.,;Bus. Tel. No.: Address: �G / L D�,Y/e-GG t2 S "L/ M ©' O ^! Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. l OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Anent The Commonwealth of Massachusetts Department of IndustrialAccidents M +office of Investigatiom ial ! 600 Washington Street .{� Boston, MA 02111 www.Yixass gov1,dia . Workers' Compensation Insilirance Affidavit: Builders/Co >'0cant Inforvrtatinn ntras;ior•s/Eieciricians/Plumberg • Name (Business/OrganizatioMndividual): i ,ca�c rr'llni LeQlbi Address: City/State/Zip: Phone #: . Are you an employer? Check.the appropriate -box: " 1. ❑ I�am-a employer with 4 ❑ l am a general contractor and I prgject (required): employees {full and/or part-time).* 2• Q I am.a.sole proprietor. or have hired the sub-contractorsewconstruction listed partner_ and have no employees on the attached sheet #emodelingship These sui3-contractorshave emolitionworking for me in any capacity, workers com .insurance P 'workers' comp. insurance.[No 5. ❑ We are a corporation and itsrequired uilding addition' [eo� ] 3. ❑ I air s homeowner doing officers have exercised their ectricaI repairs or additions all work myself. [No•workers' comp. right of exemption per MOI, c. 1.52, § 1(4),'and we have noirtsurance•re umbing repairs or additions uired. t ] employees. [No workers' of repairsq *Any comp. insurancerequired] her applicant that checks bob# 1 trust also fill outthe senfonnetion. ction below showing their workers' compensation policy i t f lomeownets who submit this affidavit indjcating they am doing all work and then hire outside contractors must submit a new affidavit indicating -' #Contractors that cherlt this box rnustrttecled such. an additional Fh7et slto wi the came efthe sub-conttactnr, m±d their tverka s' comp. policy infbnnation. Iard a?sst ew,10yQrthat es pyoyadaflg:wOilsePr' injorrraation. ' cO,�saEHsadaore lfasuFa.,tceforw eiwloyees. Below is the palecyand job sbLe Insurance Company Policy # or Self -ins. Lie. Job Site Address: Expiration Date: r4c'mtate/Zip: Attach a copy of the workers' cotnpensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a - fine up to •$1,300.00 and/or one-year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a fine Of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby certify under the pains attd penalties of pedury that the information provided afioye is true aryl correct: Sienature:• Date: official use only. ,Do not wrie i_" tris a: ea, to be co.:,,pseaed by cuy or tawa o fcial City or Town: Permit/License .. Issuing Authority (circle one): 1. Boa rd of health 2. BuildiRg Department 3. City/Town -Clerk 4. Electrical Inspector 6.Other 5. 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'4` TOWN OF NORTH ANDOVER n PERMIT FOR GAS INSTALLATION This certifies that ........................`.~�. has permission for gas installation.....:.. ................... in the buildings of ...........:.............................. ti at ...... .............................. North Andover, Mass. Fee .:...:... Lic. "No. � L l.7 ... ............ GAS INSPECTOR i Check # 3.3r-.' MASSACHUSETTS UNIFORM APPLICATON FOR PERNITT TO DO GAS FITTING (Type or print) Date/ j,, NORTH ANDOVER, MASSACHUSETTS y /� Building Locations (�` d S GGCAC S % Permit# Amount $ Owner's Name New ❑ Renovation a Replacement ❑ Plans Submitted ❑ (Print or type) /� / C k one: Certificate Installing Company 1:2Name y AAny'r,17 c.4 x L1 Corp. Address i Business U, Name of Licensed Plumber or Gas Fitter V, ❑ Partner. © Firm/Co. INSURANCE COVERAGE Check one: I have a currant liability Insurance policy or it's substantial equivalent. Yes ® No ❑ Ifyou have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy ® 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 I nereoy ceraty that au of the detalis and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions ofthe Massachus"te Gas Cod7d 1 h17 Y of the General Laws. ICity/Town VED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber /9 Z/ J 0 Gas Fitter License Number 'Master ❑ Journeyman Date! 1 ..... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that'wi....?'� has permission to perform plumbing in the buildings of .... ......- .................... . at 1!.....:....' `{ q .............. . North Andover, Mass. Fee. �.. ��I.. Lic. No./Ay/7 ........... PLUMBING INSPECTOR Check # 5047 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS 7 Date — — Building Location (j S (�G�S %owners Name ��`j y f s Permit # Amount �d Z Type of Occupancy New Renovation E' Replacement Plans Submitted Yes No FliTlRES ------------------------ME w,li� „'MIMMIMMIMMIMMIMMIMMIMMIMMIMMIMMIMMIM� l $$' mmmmmmmmmmmmmmmmmmmmmmmmm 1l,'MMMMMMMMMMMMMMMMMMMMMMMMM (Print or type) . Check one: Certificate Installing Company Name /i/i N , �° ' wC .nc[, LA. 1y El Corp. Address Partner. Business Telephone 7 _ g �— 7- y Y-5 Firm/Co. .� j Name of Licensed Plumber: /u c c�L f,:>/ /U r vc o Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy a Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner 11 Agent F1 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plionb�and Chapter 142 of the General Laws. By Sig—nature oLicenseu er��°�/ Type of Plumbing License Title / © 2/ -'7 City/Town icense u er Master 151- Journeyman ❑ APPROVED (OFFICE USE ONLY Location elel,y�'� ay� S No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # ` C� Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING Map and Parcel Number: UMap Lum Parcel er BUILDING PERMIT NUMBER: DATE ISSUED: /. 1.3 Zoning Information: Zoning Distrid Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft i��l C(Q",�, SIGNATURE: Building Commissionerfl for of Buildings Date OT4-11 R111 1-.711L' Ill\1''kiniva 110111 1.1 Property Address: l f 1.2 Assessors Number Map and Parcel Number: UMap Lum Parcel er 1.3 Zoning Information: Zoning Distrid 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 Required Provided 1.7 Water Supply M.G.L:C.40. 54) 1.5. Flood Zane Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSE IP/AUTHORIZED AGENT 2.1 Owner of Record IjW-1- ^ f /'illi AA.r�5 !\�iY�N W -L.0 V'Vu game (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: y l i �.. �i (c2 // 1 k) r.. 1 t�Li y W SECTION 4 - WORKERS COMPENSATION (KG.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ 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: ' g 1( �, J ' d.l, J') 6 ' RP Ms, aha (_a kJf--f J ad e-)v.I-- CLIJ► A4 1, 1 SECTION 6 - F.STYMATF.D CONSTRUCTION COSTS 1 Item Estimated Cost (Dollar) to be r fOFI1IIALJE�f)N.Y g Completed by permit applicant �;�°�' .. :' �'_', 1. Buildingi U (a) Building Permit Fee 1 3S, o v b Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) UUU �r �- 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUII.DING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIlMIBERS 1sT 2 ND 3 RD SPAN DHAENSIONS OF SILLS DMMNSIONS OF POSTS DMIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL, OF CHIIVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE .0 FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. ""APPLICANT FILLS OUT THIS SECTION""" "'" *'k � APPLICANT- 7ftc_A5y-,, PHONE �8 �'J-)f LOCATION: Assessor's Map Number PARCEL SUBDIVISION L LOT (S) STREET US�19t�d �`"�7 ST. NUMBER 71'q OFFICIAL USE ONLY RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS COMMENTS FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm aaw The Commonwealth of Massachusetts .Department of Industrial Accidents ' Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Name: Location: City Phone # I am a homeowner performing ell work myself. F-1 I am a sole proprietor and have no one working in any capacity I am an emplo yer providing workers' compensation 11;Pa for my employees working on this job. ('.mmn nv name- ���t'{� l.<6A�����!?1 0 (/h V City t-tri�v�►� %t4 3`�fl til ���L� Phone#. /:2 1.„c ummn^o r_., r_0 6e.�,V&J v Policv.# Oo 7 S 3 � Company name: Address Cry Phone #: Failure to secure coverage as required under`Sebtion 25A°or MGL 152 can lead to fhe imposition of -criminal -penalties of,a fine up to and/or one years' imprisonment-as-weD_as-civil.penaltiesinSheinrmjof-aBTDP_wORKDRDERmd_aJine_of_k$1QO_0W_a_day.e4c sins: understand that a copy of this statement may be forwarded'to the Office of Investigations of the DIA for coverage verification. /do hereby certify under the pains and penalties ofpequ that t e information provided above is true and correct. Print name /,f /ilk wp�, �— Phone 7if Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensi— El Building Dept E] Check if immediate response is required 0 Licensing Board p Selectman's Office Contact person: Phone # Health Department Other Town of North Andover t4ORTH Building Department 0 h..;l_ •. 6 0 27 Charles Street North Andover, Massachusetts 01845 (978) 688-9545 Fax. (978) 688-9542 °�, �+ y ° 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 cl 1, s150a. The debris will be disposed of in /at: -70 yA_01 Av 6,NA1,0A GI-VA11-4e . racuity location Signature of Applicant 61 Date NOTE: A demolition permit from the Town of North Andover must be obtained for this his through the Office of the Building Inspector. OWMENUM 814osgoS DAVID FLEMING & ASSOCIATES LAND suRvakroRs 38 POND STREET rAx iS ») 43.9-0 136 STONEHAM, kASS. (6 ») 579-0725 '5v MORTGAGE INSPECTION PLAN This plan was not done with an Instrument survey and Is to be used for mortgage purposes only. OA TE.' 10-3-99 SCALE. • 1 "= 30' I certify that this dwelling Is located approximately as shown and conformed to the zoning bylaws of the Town of No Andover MA when constructed and Is not located In a flood plain hazard zone. C',F.2T7F11-0 td EST P ivc Deed & Plan Reference Essex County Reg. of Deeds BOOK 808 / PAGE 93 N/T' SMITH N/r SM1 TN 170.58' 2¢, 000 S F. N OSCOOD STJEET N/Y SMI TN m C6 Cb a L Cf) m m m m m 0 m _) C � d V)CD n n Z vs CD -v � � C d =• y )::NCO -00 � 0 v CD CDCML o Ck) CD CCD o CSD ov ov C CD Vf' co � O y CD � v H O CD O ..� O CD O CD c �-0 o O -• N O Q N d � m .� y CD 0 o C) o H m Z =•Co cm CA p, .�•►d� O —CL 0 T CD a?d CO) N -{ O m CO) o �•1 N i gg m a C., ro- to -� Oto � o � � ♦ t.�\ o N• nCD 6. CO) co oz ZJ CD m a l J c � Q m 3 _ 1"S. d N f� O N CL d cc ro a 3 U .a C7 CD e H cn \y ` o : O =m f O Com: \� z CD = o Qk) pq tI7: 1 a-) Q :� o CD . O C -)0L CD � o 0 cn :� J OCD y 0 O C rn �*T `%' x -x g n o 0 rrD U o �i °� - T � w ?. � t�1 r n rA °� ; a- "d b t� w � a ? CL o 0 r cin �^ r < x0 a O rr y 0 O C FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all -necessary approval / permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANT PHONE ASSESSORS MAP NUMBER LOT NUMBER SUBDIVISION —�� LOT NUMBER STREET O� l-�C�� v! STREET NUMBER OFFICIAL USE ONLY ............................................................................ . _ RECOMMENDATIONS OF TOWN AGENTS DATE APPROVED X CO SERVATION AD91NISTRATOR � j r DATE REJECTED COMMENTS V tr)e �1� �l S iy •� ( o (j O DATE APPROVED T QP DATE REJECTED COMMENTS FOOD INSPECTOR - HEALTH SEPTIC INSPECTOR - HEALTH I,-, -- e- \/a 1 c)(3 +ie_ J D G r'clp ri e C-3 F— / J PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED sy s1c, a) __� �� s h ly ��LrL)e� DATE APPROVED DATE REJECTED RECEIVED BY BUILDING INSPECTOR DATE 3a-15= 30 �D 814os o DAVID FLEMING & ASSOCIATES MORTGAGE INSPECTION PLAN LAND SDRyaYORS This plan was not done with an instrument survey 38 POND STREET fAX and Is to be used for mortgage purposes only. (617) 436-0136 STONEHAM, MASS- (617) 276-0725 DATE: 10-3-99 SCALE: 1 "= 30' I certify that this dwelling Is located approximately as shown and conformed to o • the zoning bylaws of the Town of ., when constructed and Is not located In a flood plain hazard zone, ? e C,6e77F/FA070 f tv6.ST P �i+•C t o Deed & Plan Referencea Q m Essex County Reg. of Deeds g a BOOK 808 / PAGE 93 N/1• o SMI7H r Nlr SMI TH 0 OSCOOD STREET TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING ------ � r.�:�, 1 BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/InELxctor of Buildings Date SECTION I- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: c�c9 /Zoning Map Number Parcel Number 1.3 Information: 1.4 Property Dimensions: ��C��'ir vc o29© / ZoningDistrid Proposed Use Lot ea s Frontage ft 1.6 BUILDING SETBACKS ft -Front Yard Side Yard Rear Yard Required Provide Required Provided R red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (Print) Address for Service : ,f 1 5� , 4 /• (fu 7�P Signa re'V'W, �,Z-F— rIRI-17 Te ephone ci 2. Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ . ��v�✓N Cis Licensed Construction Supervisor: �( e r / U l �� e JN /tel /` License Number �.eO74 � �� j f � Addr ss llllld,?- E ration ate Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ rL-A' 74W-- (�j Company Name U 2 a � ��r /'r`✓•P �-t T' (�v-��r -r C1��� do I ! j ����1 /,V, Registration Number / //J^/v2G27G Address Expir tion D to Si nature Telephone V M z O O Z M 90 O mn e r 0 M _r 2^ Y/ i f \ J l 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 ....... 11 No ....... ❑ SECTION 5 Description of Proposed Work check all applicable= New Construction ❑ 1 Existing Building ❑ I Repair(s) ❑ 1 Alterations(s) Addition Accessory Bldg. ❑ I Demolition ❑ I Other ❑ Specify Brief Description of Proposed Work: I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be}FFFCIAL Completed by pen -nit applicant USE tiNLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Q <7G Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, , as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION7bOWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief ile Print Si ature of Owner/A ent Ilate NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS ,2�/ 1 /_ �/ 2 Z.� ley 3 PD SPAN DIMENSIONS OF SILLS 2 - DIMENSIONS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS /O'-, SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND /r IS BUILDING CONNECTED TO NATURAL GAS LINE c= S S The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: S ky47 //l 6, 1-e to 7 r A,- 6217 i� City 111le %�(�✓° 1 Nle Phone /P7CI = am a homeowner performing all work myself. =I am a sole proprietor and have no one working in any capacity l am an employer providing workers' compensation for my employees working on this job. City: &- Ch's ���(, Phone #: -, %F 6_211 7� �7`3 iS' h�>° 'Policy# �t/Cr %�U '7_siG A Insurance Co. �4.C' � ��svo � Company name: Address City: Phone #: Insurance Co Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 andtor one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains an - pen , ep peq that the information provided above is true and correct. cj...,mrii�o_ Date �/ (, /.Z Print name Sf' Phone Official use only do not write in this area to be completed by city or town official' ❑ Building Dept ❑Check if immediate response is required Building Dept ❑ Licensing Board ❑ Selectman's Office Contact person: phone #. ❑ Health Department ❑ Other FORM WORKMAN'S COMPENSATION Inc. CONTRACTING BUILDING T REMODELING This agreement made this $ day of Oc-fc6{r-, year Nineteen hundred and ninety nine by and between Cote and Foster Contracting, Inc. hereinafter called the Contractor and Blair Roberts and Karen Jacobson hereinafter called the Owners, witnesses that the Owners are constructing a 16'x22' two story addition, first floor family room, second floor bedroom, first floor 3/4" bath, second floor full bath, remodel existing second floor abutting bedroom with a laundry room, new bed closet and hall to access new bedroom, and screen room. Now, therefore, the Contractor and the Owners, for consideration hereinafter named, agree as follows: ARTICLE 1 The Contractor agrees to provide all the labor and materials to do all things necessary for the proper construction and completion of the work shown and described on drawings. The drawings and specifications are the basis of the contract. ARTICLE 2 Inconsidera - n of the performance of the contract, the Owner agrees to pay the Contractor, in cuant funds as compensation for his services hereunder $107,150.00 to be paid as follows: ayment 1: $10,000.00 at the contract signing. Payment 2: $10,000.00 at the completion of foundation. Payment 3: $15,000.00 at the start of framing. Payment 4: $20,000.00 at the completion of frame. Payment 5: $20,000.00 at the completion of rough plumbing and electrical. Payment 6: $20,000.00 at the completioin of dry wall and insulation. Payment 7: $8,000.00 at the completion of interior finish. Payment 8: $2,150.00 at the completion of interior paint and tile. Payment 9: $2,000.00 at the completion of project. ARTICLE 3 Final payment on contract amount as agreed above to be paid within ten (10) days of project completion or occupancy. If final payment has not been made within this time a 10% charge per month on the balance due will be charged. All minor punchlist items will be complete as part of the one year warranty on the finish product. Failure to pay balance within ninety (90) days may result in legal action. Initials -0� K ARTICLE 4 Additional work above and beyond the contract agreement. All additional work done to be quoted at the time the client requests the work. The work will be done and billable at its completion. The client has ten (10) days to pay the additional cost after he or she has been billed for it. Initials 20 Aegean Drive • Unit 15 • Methuen, MA 01844 • Tel: 978-682-6518 • Fax: 978-682-1221 a fid CONTRACTING BUILDING T REMODELING Page 2 Roberts / Jacobson Contract in witness whereof they have executed this agreement the day and year first above written. Blair Roberts Karen Jaco son Steven M. Cote DBA Cote & Foster William T. Foster DBA Cote & Foster 20 Aegean Drive - Unit 15 - Methuen, MA 01844 - Tel: 978-682-6518 - Fax: 978-682-1221 MAScheck COMPLIANCE REPORT Massachusetts Energy Code MAScheck Software Version 2.01 Release 3 CITY: North Andover STATE: Massachusetts HDD: 6322 CONSTRUCTION TYPE: 1 or 2 Family, Detached HEATING SYSTEM TYPE: Other (Non -Electric Resistance) DATE: 6-5-2000 COMPLIANCE: Passes Maximum UA = 193 Your Home = 181 Permit # Checked by/Date The heating load for this building, and the cooling load if appropriate, has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 125% of the design load as specified in Sections 780CMR 1310 and J4.4. Builder/Designer Date Area or Cavity Cont. Glazing/Door ------------------------------------------------------------------------------- Perimeter R -Value R -Value U -Value UA CEILINGS 704 38.0 0.0 21 WALLS: Wood Frame, 16" O.C. 1080 13.0 0.0 89 GLAZING: Windows or Doors 150 0.280 42 DOORS 70 0.280 20 FLOORS: Over Unconditioned Space ------------------------------------------------------------------------------- 352 38.0 0.0 9 COMPLIANCE STATEMENT: The proposed building design described here is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the requirements of the Massachusetts Energy Code. The heating load for this building, and the cooling load if appropriate, has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 125% of the design load as specified in Sections 780CMR 1310 and J4.4. Builder/Designer Date .05125!2000 08:33 5086825787 NL MEDICAL RECORDS Town f North Andover OFFICE OF COMMt NM DEIIELOPNMNT AND SERVICES 7 Charles Street North An over, Massachusetts 01845 WILLIAM 1. SCOTT Director (978)688-9531 Q Any appeal shall be filled within (20) days after the date of filing this Notice in the Office of the Town Ci+t & Petition of: Caren Jacobson and Blair P G OF DECISION PAGE 02 Fax(978)688-9542 Premise9 affected: 814 Osgood Street Referring to the above petition for a special permit from the requirements of the. North Andover Zoning Bylaw Section 4.136 so as to allow: the construction of a two dwcftg located within the Watershed Pr, After a public hearing givers on the To: APPROVE the: Watershed,,' CC: Director of Public Works Building Inspector Natural Resource/Land Use health Sanitarian Assessor$ Police Chief Fire Chief Applicant Engineer Towns Outside Coosnitant File Interested Patties addition and screened porch tO an existing on District. date, the Planning Board voted d Permit based upon the following conditions (attached): Signed bison K Les Cart Mu. Cb2irtrtan Jahn S' as Vice Chairman Albert! o Ane . Clerk RiS. Rowan R'chat d Nardella Planning Board BOARD OF APPEALS 688-9541 BULL LANG 688-9345 1 CONSERVATION 6M9530 HEALTH 689-9540 PLANNING 688-9535 x �- c., c -� xz�Q N "D 5MC m v <x� Date: May 12, 2000 Date of Hearing: May 2, 2000 Premise9 affected: 814 Osgood Street Referring to the above petition for a special permit from the requirements of the. North Andover Zoning Bylaw Section 4.136 so as to allow: the construction of a two dwcftg located within the Watershed Pr, After a public hearing givers on the To: APPROVE the: Watershed,,' CC: Director of Public Works Building Inspector Natural Resource/Land Use health Sanitarian Assessor$ Police Chief Fire Chief Applicant Engineer Towns Outside Coosnitant File Interested Patties addition and screened porch tO an existing on District. date, the Planning Board voted d Permit based upon the following conditions (attached): Signed bison K Les Cart Mu. Cb2irtrtan Jahn S' as Vice Chairman Albert! o Ane . Clerk RiS. Rowan R'chat d Nardella Planning Board BOARD OF APPEALS 688-9541 BULL LANG 688-9345 1 CONSERVATION 6M9530 HEALTH 689-9540 PLANNING 688-9535 05f25/20Q0 05:33 5086825737 814 Usgaad Street Special Permit - Watershed District NL MEDICAL RECORDS The Planning Hoard makes the follc wing findings regarding the application of wren Jacobson and Blair Roberts, 814 Osgo od Street, North Andover, MA 01845, dated March 17, 2000, requesting a Special Permit inder Section 4.136 of the Zoning Bylaw to allow the construction of a 492' square foot ad lition and screened porch within the Non -Discharge Zone of the Watched Protection Disttict. FINDINGS OF FACT: In ardance with 4.136(4) the Planaing Board makes the fording that the intent of the Bylaw, as well as its specific criteria, are met. Specifically the Planning Board finds: 1) That as a result of the proposed co struction in conjunction with outer uses nearby, there will not be any significant degrad ion of the quality or quantity of water in or entering ,Lake Cochichewick. The Plannin Board bases its findings on the following facts: a) The proposed project is loca approval from the Board of H not have a flow inerme to the b) The increase in runoff result Management Practices — the a wetlands. c) Construction of the addition away from Lake Cochiewick; d) The rooftop runoff, which is c Department ofEnvironmental on a septic system which has received prior — the applicant has stated that this proposal will ting septic system; from this construction will be treated by Best rg catch basins on Osgood Street and tate existing the screened porch is approximately 2000' feet to be uncontaminated by the Massachusetts will be recharged into the ground. 2) That there is no reasonable alternative location outside the Non -Disturbance Zone for any discharge, structure or activi , associated with the proposed project because no portion of the applicant's lot is Dutside this zone, therefore there is zio practicable alternative to construct the additior outside this zone. In accordance with Section 10.31 of makes the following Findings: A. The specific she is an appropr water and erosion controls have B. The use will not adversely affect zone; C. There will be no nuisance or D. Adequate and appropriate use; North Andover Zoning Bylaw, the Planning Board location for the proposed use as all feasible storm I placed on the site; neighborhood as the lot is located in a residential hazard to vehicles or pedestrians; are provided for the proper operation of the proposed PAGE 03 m i NEW ENGLAND ENGINEERING SERVICES INC April 10, 1997 Blair Roberts 814 Osgood Street North Andover, MA 01845 RE: Title V Report at 814 Osgood Street, North Andover, MA 01845 Dear Sir: Enclosed is your copy of the Title V Report. Your system passed the inspection. A copy of the report has been mailed to the North Andover Board of Health for their records. If there are any questions regarding the report please feel free to call. Yours truly, . Jamin C. Osgood Jr., E.I.T. resident 33 WALKER RD. - SUITE.22 NORTH ANDOVER,. MA 01845 - (508) 686-1768 MUM K Wild Gowwrow tm19ul Celluccl 1. Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of gnAronMehital Protection. TrudY9-01" David B. Struht . ca,„mwior,.r /. &-- Trudy Cox* 9-01" -- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION P'°Per'ty Address:$ l t f (i S C* oo ST. M. R Ne o V 9•IZ 9'7 Address a Owner. Date of Inspbotion: 3�0c/(It dlfternt) Nafne of Inspector. Benjamin C. Osgood Jr. Company Name, Address and Telephone Number. New England Engineering Services, Inc. 33 Walker.Road, North Andover, Ma 01845 CERTIFICATION STATEMENT Tel: 508-686-1768 Fax, 508-685-1099 I certify that I have personally. inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function afid maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: gy Date:y/9/g 7 The System Inspector shall submit a copy of this inspection report to the Approving Authority within inspection. It the systkm is a shared system or has a design now of 10,000 �y (30) days of completing this report to the appropriate regional office of the De °r greater, the inspector and the system owner shall submit the The original partment of Environmental Protection. should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY.. Check A, B, C, or D: A) SYSTEM PASSES: Y have trot tound Any intormatfon which indicates that the system violates iffy of the failure criteria as defined is 310 CMR 16.303. 1' f iiia i:cite"rid iiot evahiatpd arE thiledted bdlo*. i 131 SYSTEM. CONDITIONALLY PASSES: One or morb system component* heed to be replaced or repaired. 'rho system, upon completion of the replacement or repair, passes Indicate ye7t, no, or hot determined (Y, N, or ND). Describe basis of detbrmination In all instances. It"not determined", explain why not) The septic tank is metal, tracked, stritcturaUy unsound, shows substantial infiltration or exfiltratio imminent. The systein will pass inspection if the existing septic tank is replaced with a Fonfo or` failure is by the Board of Realth. g septic tank as.approved (revised it/03/95) 1 One Wintei Street a Boston, M111"chubetts 02108 if FAX (617) 556-1049 �r s� Printed on Recycled papa e Telephone (617) 292.5500 I � r 1. � r MUM K Wild Gowwrow tm19ul Celluccl 1. Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of gnAronMehital Protection. TrudY9-01" David B. Struht . ca,„mwior,.r /. &-- Trudy Cox* 9-01" -- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION P'°Per'ty Address:$ l t f (i S C* oo ST. M. R Ne o V 9•IZ 9'7 Address a Owner. Date of Inspbotion: 3�0c/(It dlfternt) Nafne of Inspector. Benjamin C. Osgood Jr. Company Name, Address and Telephone Number. New England Engineering Services, Inc. 33 Walker.Road, North Andover, Ma 01845 CERTIFICATION STATEMENT Tel: 508-686-1768 Fax, 508-685-1099 I certify that I have personally. inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function afid maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: gy Date:y/9/g 7 The System Inspector shall submit a copy of this inspection report to the Approving Authority within inspection. It the systkm is a shared system or has a design now of 10,000 �y (30) days of completing this report to the appropriate regional office of the De °r greater, the inspector and the system owner shall submit the The original partment of Environmental Protection. should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY.. Check A, B, C, or D: A) SYSTEM PASSES: Y have trot tound Any intormatfon which indicates that the system violates iffy of the failure criteria as defined is 310 CMR 16.303. 1' f iiia i:cite"rid iiot evahiatpd arE thiledted bdlo*. i 131 SYSTEM. CONDITIONALLY PASSES: One or morb system component* heed to be replaced or repaired. 'rho system, upon completion of the replacement or repair, passes Indicate ye7t, no, or hot determined (Y, N, or ND). Describe basis of detbrmination In all instances. It"not determined", explain why not) The septic tank is metal, tracked, stritcturaUy unsound, shows substantial infiltration or exfiltratio imminent. The systein will pass inspection if the existing septic tank is replaced with a Fonfo or` failure is by the Board of Realth. g septic tank as.approved (revised it/03/95) 1 One Wintei Street a Boston, M111"chubetts 02108 if FAX (617) 556-1049 �r s� Printed on Recycled papa e Telephone (617) 292.5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: $ /y 0.5 &0," r-> 57= N, 19A1,0 c ✓i K Owner. Date of Inspection: 3���197 r,Bi SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to it broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will past inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 WILD FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER- PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank.and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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 6 ppm. S) OT1$EII µ. (revised 11/03/95) 2 L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: $ /y 0.5 &0," r-> 57= N, 19A1,0 c ✓i K Owner. Date of Inspection: 3���197 r,Bi SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to it broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will past inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 WILD FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER- PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank.and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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 6 ppm. S) OT1$EII µ. (revised 11/03/95) 2 'r�';t•°.pis ' 'x SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) s Property Address:. e/ y O w �a D Owner. 1 fTR Yz_ % Al. /9N0 0 Vele Date of InspeotionE lair k, lei- ! S 3iz�rg7 D) SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.903. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the fa^il�ure. V Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. { Q[ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or cesspool. clogged SAS or 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a. private water supply well with no Acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water coanalysis for liform bacteria, volatile o rgaaic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: 5 The following criteria apply PP Y to large systems in addition to the criteria above: The system serves fi facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant' health and safety and the environment because one or more of the following conditions exist: threat to public { ;' titht�systafil #s wikaitt !1001eet of li itiilace nlung water supply -- the system is "within 200 feetof a tr'butary to a surface drinking water supply ._ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a' mapped Zona 11 of a public water supply well) • ; The owner or" operator of any aitch systeln sbail bring the system and facility into full compliance with the requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the De hergrondwer treatment program ' Department for further Information. '. (revised W63/95) SI'i 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address e/'{ 0,S G- c o p5 i /V_ p ni p D V E Q Owner. 01 Ritz R o 3 r 2 T$ Date of Inspection Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health., None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. f/VA Ai built plans have been obtained and examined. Note if they are not available with N/A._ YThe facility or dwelling was inspected for signs of sewage back-up. i V The system does not receive non -sanitary or industrial waste flow The.aite was inspected for signs of breakout. ZA11 system components, excluding the Soil Absorption System, have been located on the site. I ; The septic tank manholes were uncovered, opened, and the interior of the septic tankwasinspected for condition of baffles or tease material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the lite has been determined based on existing information or appivmmated by non -intrusive methods. ! Thm facility owner (and occupants, if different from owner) ;'were provided with information on the proper maintenance of Sub- Surfack Disposal System. (revised 11/03/95) 4 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address e/'{ 0,S G- c o p5 i /V_ p ni p D V E Q Owner. 01 Ritz R o 3 r 2 T$ Date of Inspection Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health., None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. f/VA Ai built plans have been obtained and examined. Note if they are not available with N/A._ YThe facility or dwelling was inspected for signs of sewage back-up. i V The system does not receive non -sanitary or industrial waste flow The.aite was inspected for signs of breakout. ZA11 system components, excluding the Soil Absorption System, have been located on the site. I ; The septic tank manholes were uncovered, opened, and the interior of the septic tankwasinspected for condition of baffles or tease material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the lite has been determined based on existing information or appivmmated by non -intrusive methods. ! Thm facility owner (and occupants, if different from owner) ;'were provided with information on the proper maintenance of Sub- Surfack Disposal System. (revised 11/03/95) 4 property Addrem . . Owner. Date of Inspection: . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART O - SYSTEM INFORMATION 8/y US (suOo Cal ai r Ro � -�rt'S 312(./4? RESIDENTIAL: Design flow Gallons Number of bedrooms:—3 Number of current residents Garbage grinder (pee or ho): Laundry connected to system (pes or no): Seasonal use (yes or ho): At Water meter readings, if available: Last date of occupancy: G U 1, rtn•l" sTT IV, jq V D oUE2 FLOW CONDITIONS COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow:" I gallons/day Grease trap present: (YOS 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 ooenpancy: OTHER (Describa) . . Last date of occupAacy: GENERAL INFORMATION PUMPING RECORDSi and source of information: rtRd �ttn cQone � �a�c ��n �,trt0 uI N Systehj pumped " part of inspection: (yes or no) -%_4 - It yes; vohun! primped: ,JS'DO ¢allons Reason for. pumping: To l n s a t et. 1"..4 TYPE F SYSTEM 8eptk tankldisti"on box/soil absorption system g�in��,b �eeespool ,ls -::z:, t • " Sberea system (yes or no) (it' yea, attach previous Inspection records, if any) Other (explain) } , APPROXIMATE AGE of all components, date installed (if known) and source of information: I9 f3 3 f?e r- O w N t t' 4r 1 Sewage odors detected when arriving at the site: (yes or no) (revised 11/03/95) S -] SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C t SYSTEM INFORMATION (continued) • .Property Address; e l y p s lr v^ a D s T_ A), ,r} AJ D U U E Q Owner. 61ai r {Lo c r S t t Date of Inspection: 31Z6� 97 SEPTIC TANK:_ (locate on site plan) u Depth below grade: Material of construction: 1�-ooncrete _metal _FRP other(explain) Dimensions: l 1000 sludge depth .lo " Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: % Distance from top of scum to top of outlet tee or baffle: '7 Distance from bottom of scum to bottom of outlet tee or baffle: Z Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) T N Al It (ti AS Al E Al l R 8 3 44,v A I lU /.-0()/) JAJ ( 1-7 IN AJ GREASE TRAP:_ (locate on site. plan) ' Depth below grade: Material of eonstrucaon: _concrete metal _FRP other(explain) Dimensions: scum thfclnue:s: Distance from top of scum to top of outlet tee or baffle: Distance from bottom o!'scum to bottom of outlet tee or baffle: Comments: ttecombiindatiot foe pumping, condition of inlet and outlet tees or banes, depth of liquid level in relation to outlet invert, structural integrity, a AAi.*." of laelravie. 61 i (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) Property Address: 81 O s lsvv f3 AJ. #IVVVVEQ Owner. Date of Inspection: G a7 TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: —concrete ___metal __M other(explain) Dimensions: Capacity: stallons Design flow: --gallozWday Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOM (locate 8h site plan) Depth ot liquid level above outlet invert: Comment*: (note if level and dktiilyutin is equal, evidence of solids ver, evidence of leakage into_ or out of box, PUMP CHAMBER: (locate on site plan) Pumps in *otldng orderAyes or no) Commend: (note condition of pump chamber,, bohditioh Of pumps and appurtenances, etc.) it . (revised 11/03/95) 7 c SUBSURFACE SEWAGE DISPOSAL SYSTEM, INSPECTION FORM PART C SYSTEM INFORMATION (continued) Owne �ax � Addre/y Hnd�o„t'N Date of Insp cation: 91 ' r- 2 , r •- is SOIL ABSORPTION SYSTEMZ S 7 (9A9): (locate on site Plan, if possible; excavation not required, but may be aPPrOximated by non -intrusive methods) If not determined to be present, explain: Type: leaching Pte, number: leeching chambers, number._ 8 galleries, number leaching trenches, number,length: leaching fields. number, dimensions: / • 1 ca overdo* cesspool, number. Comments: (note condition of soil, a• of hydraulic. e c (� failure, level of pondi'condition of vegetation,etc•) , CE99POOL9: _ (locate on rite plan) l Number and configuration: Depth -top of liquid to inlet invert: Depth of eolith layer Depth bf .cum layer Dimensions of cesspool:., .. Materials of 66htrtictioti:., Indication of groiiudtter.. . inflow (cesipooj must he pumped as ' PHzt of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding. condition of vegetation, Be a, etc.) PRIVY: _ (locate on site plan) Materials of construction: Depth of solids: Dimensions: Comments (note condition of soil, signs of hydraulic failure level of ponding, condition of vegetation, etc.) (revised 11/03/95) 8 BOARD OF HEALTH NORTH ANDOVER, MA 01845 978-688-9540 APPLICATION FOR SOIL TESTS E DATE: MAP & PARCEL: LOCATION OF SOIL TESTS: ' i �= ��• �} = s} '' ��� l` c' �� ,�°� O WNER: ( fA � ti ti_ ` S «<�� -,,,y. �5 (."4`C,.4TEL. NO. ADDRESS: `5 c1d ENGINEER: ��< 1 I L..'y,, I�1 wry �, TEL. NO.: CERTIFIED SOIL EVALUATOR: Intended Use of Land: Residential Subdivision Single Family Home Commercial Is This: Repair Testing: )� In the Lake Cochichewick Watershed? Undeveloped lot testing: Yes No THE FOLLOWING MUST BE INCLUDED WITH THIS FORM 1. Proof of land ownership (Tax bill, or letter from owner permitting test) 2. Plot plan & Location of Testing 3. Fee of $275.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of $75.00 per lot for repairs or up rg ades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. 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). 7. Within 60 days of testing soil evaluation forms shall be submitted. Please Do Not Write Below This Line N.A. Conservation Commission Approval: Date Received: Check Amount: Check Date: 814osgo F9 "S .dBW DAVID ,F'LEMING & ASSOCIATES LAND SURVEYORS 38 POND STREET W tX17) 4.3a-0136 STONEHAM, MASS. (617) 279-0715 MORTGAGE INSPEC77ON PLAN This plan was not done with an Instrument survey and Is to be used for mortgage purposes only. DATE: 10-3-99 SCALE. -1"= 30' l certify that this dwelling Is located approximately as shown and conformed to the zoning bylaws of the Town of No Andovegr MA when constructed and Is not located In a flood plain hazard zone' is �• �, �, �., r„ . cv c17- WEST �.a7 �P ";t,C Deed & Plan Reference Essex Coun ty Reg. of Deeds BOOK 808 / PAGE 93 N/r SM1 TH N/F SMI TH NIT SMI TH rn s. Ch rn CL OSCOOD STREET jol�o ut j 0— 00 -OC William F. Weld Gomm Argeo Paul Cellucci LL Governor Commonwealth of Massachusetts r ; Executive Office of Environmental Affairs 51992 Department of t ppR Environmental Protection Trudy Coxe Snc st" David B. Struhs cotnmfaioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 8 R( OS (>-4210 D 51- M. ANp C vCR Address of Owner. Date of Inspection: 312 (-1'9 7 (If different) Name of Inspector. Benjamin C. Osgood Jr. Company Name, Address and Telephone Number. New England Engineering Services, Inc. 33 Walker Road, North Andover, Ma 01845 CERTIFICATION STATEMENT Tel. 508-686-1768 Fax. 508-685-1099 I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: l6 t y.. e /J � Date: tr/c�/1 7 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the. system owner shall submit the report to the appropriate regional office of the Department of Environmental protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: Al SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) One Winter Street • Boston, Massachusetts 02106 • FAX (617) 556-1o49 • Telephone (617) 292.55W A ii Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: E3 /Y QS &0,, p 5 7= N, 19,v O C O J Owner. S /a i r Date of Inspection: 3/z6�47 B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): broken pipe(&) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 C1 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. 3) OTHER (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Addreew 8/ AI Owner. l %l Y n/ . /7/VO O VzFk Date of Inspection: al2iolq� D) SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. V Backup of sewage into facility or system component due to an 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. -LV Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. L 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. ,11L Any portion of a 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. /L Any portion of a cesspool or privy is within 50 feet of a private water supply well. 1 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist; — 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 Property Address Owner. Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST sly 0"5 &-C0a BI141R /Zo 3 CRTs 3/ 21-/ q ? si /v_ q,vpt)VER Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. NA As built plans have been obtained and examined. Note if they are not available with N/a VThe facility or dwelling was inspected for signs of sewage back-up. The system does not receive non -sanitary or industrial waste flow Y The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non -intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub. Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: $/ y (J S &-000 Owner. 131 A} N` 1qti D vVE1? Date of Inspection Rt' 5 31 q7 FLOW CONDITIONS RESIDENTIAI: Design flow: ¢aeons Number of bedrooms: 3 Number of current residents: Garbage grinder (pen or no)•_ Laundry connected to system (yes or no): uc S Seasonal use (yes or no): At 7" Water meter readings, if available: Last date of occupancy: G u ren COMMERCIAL /INDUSTRIAL• Type of establishment: Design flow:_Kallons/day 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: OTHER (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Has i�eenrQ�ne rQ,,TC System pumped as part of inspection: (yes or no)_4_ If yes, volume pumped: I S"D O gallons Reason for Pumper Ty Inc o e, TYPE QF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: / C/ ,pe r- p w N t t' Sewage odors detected when arriving at the site: (yes or no) /V - (revised 11/03/95) Property Address: Owner. Date of Inspection: SEPTIC TANK:_ (locate on site plan) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 05lrv6D ST_ 61«;� R.cr-t5 97 N. A1/D0U67Q u Depth below grader Material of construction: Zooncrete _metal _FRP —other(explain) Dimensions'-- /CDU (fi L w ,V Sludge depth: Distance from top of sludge to bottom of outlet tee or bafile:2 Scum thickness: / , It Distance from top of scum to top of outlet tee or baffle:_Z Distance from bottom of scum to bottom of outlet tee or baffle: 2 / Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) D9 Al (< to l ►9S Al E(M' l q S 3 ZflN A (/U Croon C'.JA.10c 1_2t1 eU GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: o i Y O, (�vv D sT/U. ftNv� �� 2 Owner. glai Date of Inspection: r e0 b,:/-ts 31 ZG1a7 TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids IJ n X / n Gr o u cX "'. ,— J PUMP CHAMBER_ (locate on site plan) Pumps in working order:(yes or no) evidence of leakage into or out of box, Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: S / y Owner. Date of Inspection: 3f Z��y7 SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: &-T= leaching pits, number:_ leaching chambers, number._ leaching galleries, number- leaching umberleaching trenches, number,length: /� leaching fields, number, dimensions: / lc.Q overflow cesspool, number: Comments: (note condition of soil, si of hydraulic failure, level of pondin condition of vegetation etc.) a reA O r i"1 e (cQ /o u &I c o �• .t' CESSPOOLS: _ (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: _ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 11/03/95) 2 Property Address: Owner. Date of Inspection: .► SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMA/1TION (continued) C,t U!V v s COcSv $/a i r� 3%Z G19 y SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 1 OT 2 i DEPTH To GROUNDWATER -' 1 Depth to groundwater.—!Z_feet method of determination or approximation: _/ �n v w �� oG 9 e (revised 11/03/95) 9 FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANTKrjr,.-\ )`Y c.�-'35v. . PHONE � % �' �u�c: Jr%+ LOCATION: Assessor's Map Number PARCEL SUBDIVISION 1 LOT (S) STREET �&>) ST. NUMBER `e� L OFFICIAL USE ONLY RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER COMMENTS DATE APPROVED DATE REJECTED FOOD INSPECTOR -HEALTH DATE APPROVED ,4 DATE REJECTED SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED 7 ZZ 2 C) DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR Revised 9197 jm TE Date.... / f 1..... /..... N° 3 5 , -3..... . rM.' T"1"°TOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that .........� �� Cc ' .—{ t C ................................................................................... has permission to perform ...... i L'.( ... A�:.:: � K................................................. wiring in the building of ................................................. at ............ .y�.f ..... �: .. �• �, �1r.... ......... * North Anddoo�ver; Mass Fee..7)..,.6.1). Lic. No.....4f17v........ ` ELECTRICAL INSPECTOR Check # M WHITE: Applicant CANARY: Building Dept. PINK: Treasurer The Commonwealth of Massachusetts Office Use Only Department of Public Safety Permit # a Board of Fire Prevention Regulations 527 CMR 12:00 Occupancy & Fee Checked 3190 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date January 2, 2002 City or Town of No. Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) 814 Osgood Street Owner or Tenant Karen Jacobson Owner's Address Same Is this permit in conjunction with a building permit: Yes No = (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead =Undgrd =No. of Meters New Service Amps Volts Overhead =Undgrd =No.ofMeters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No. of Lighting Fixtures 37 Swimming Pool No. of Receptacle Outlets 22 No. of Oil Burners No. of Switches 24 No. of Gas Burners No. of Ranges No. of Disposals No. of Dishwashers No. of Dryers No. of Water Heaters No. of Hydro Massage Tubs Other: (1) sub panel No. of Air Cond. I No. of Heat Pumps I Space / Area Heating Heating Devices No. of Signs No. of Motors INSURANCE COVERAGE: Pursuant to requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES � NO I have submitted valid proof of the same to this office YES I " NO 1 If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE ( " 1 BOND F-7 OTHER (please specify) 2/2/02 Estimated Value of Electrical Work (Expiration Date) Work to Start January 2, 2002 Inspection Date Requested: Rough 3 -Jan Signed under penalties of perjury: Final Upon Request FIRM NAME Dumais Electric LIC. NO. 12170A Licensee Mark A. Dumais Signature -�99, e, LIC. NO. 26665E Address 8 Newport Street Bus. Tel. No. 978-683-9438 Methuen, MA 01844 Alt. Tel No. 978-685-4553 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or it's substantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (please check one) r d Telephone No. Permit Fee (Signature of Owner or Agent) Kitchen, Family Room, Laundry Room, 3 Bathrooms No. of Transformers Generators No. of Emergency Lighting Battery Units I Tons kw kw kw FIRE ALARMS No. of Detection No. of Sounding No. of Self Contained Local Municipal Low Voltage Wiring INSURANCE COVERAGE: Pursuant to requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES � NO I have submitted valid proof of the same to this office YES I " NO 1 If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE ( " 1 BOND F-7 OTHER (please specify) 2/2/02 Estimated Value of Electrical Work (Expiration Date) Work to Start January 2, 2002 Inspection Date Requested: Rough 3 -Jan Signed under penalties of perjury: Final Upon Request FIRM NAME Dumais Electric LIC. NO. 12170A Licensee Mark A. Dumais Signature -�99, e, LIC. NO. 26665E Address 8 Newport Street Bus. Tel. No. 978-683-9438 Methuen, MA 01844 Alt. Tel No. 978-685-4553 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or it's substantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (please check one) r d Telephone No. Permit Fee (Signature of Owner or Agent)