HomeMy WebLinkAboutMiscellaneous - 93 RALEIGH TAVERN LANE 4/30/2018N �
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ..... ....... a w. ze .........................................
has permission to perform .......... A—M�elg ........ ............................ ; .........
wiring in the building of ... .......... VOY-:5A,11f /P ft?lz ............
.................................. 4-, North Andover,- Mass.
Fee.� ......... Lic. No.&? ............... ! .....
ja Check # -1-6 MY EUCMCAL INSPECTO I R /
6 6'e- 3
2012 Massachusetts Electrical Code Amendment's 527 CAM 12.0o § Rule 8: In accordance -with the Provisions of M.G.L c. 43 § 3L
Permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applicat - I , , the
On the Prescribed forin. After a permit application has been accepted ions shall be filed
by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification Of completion of the work as required in M.G.L. c. 143, § 3L -
Permits shall -be limited a� to the time ofongoing construction activity; and may'be-deemed-by-the-Inspector-of-W-ires abandoned-and-in-v.alid-ifhe—.--
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upo iften
application, an extension of time for completion of a wr
request of either the owner or work shall�be permitted for reasonable cause. A permit shall be terminated upon e written
-the installing entity stated on the Permit application. . - th
The Permit Extension Act was created by 5ection 173 of Chapter 240 of the A cts of 20 10 and extended by Sections.74 and 75 of Chapter 23 8 of
the Acts of 2012. The purpose of this act is to promotejob growth and long-term economic recovery and the Permit Extension Act finthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerningthe use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on Augu
5j, 2008 and extendingthrough August 15, 2012.
; X Rule 8 — Permi
t/D.ate Closed:
El Pernlit Extension Act — Fermit[Date 'Closed:
Note: ReaP'Ply for new permAK-1.,
'A
.C-\,
BOARO OF FIRE PREVEN71ON REGULA71ONS
Official Use Only
Permit No.
Occupancy and Fee Checked
,,[Rev. 1/07) (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with, the Massachusetts Ele=ical Code NBC), S27 CUR 12.00
(PLEASE PPJNT N NK OR TYPE ALL INFORA" TION) Date: 2/23/09
City or Town Oh North Andover To the Inspector of Wires:
By this 4PPlication the undersig! 12 1 12 NS ri Yti C! 3 or her intention to perform the eiectrical work described beioA,,
Location (Street & Number) 93 Raleigh I Tavern Ln
Owner or Tenant Kurt Von
Tel—hone N,, Y / 6_ZU6_TrM
Owner'sAddress 93Rgleigh-T . avern Ln, North Andover, MA 0 1845-5625 - -----
Is this permit in conjunction with a building permit? yes No (Check Appropriate Box)
l'urpose of Bufiding Residential - I family
Utflk Authorization No.
Existing Service Amps
Volts Overhead Undgrd No. of Meters
New Servic Amps Volts Overhead Undgrd No. of M ieters
Number of Feeders and Ampacity
Location and Nature of Proposed.Electrical Work: �0
'o k 0 C
No. of Recessed LuminaEes
COMvietit-7f the following
table mav be waived bv the InsDector qrWires,
o.
No. of Celll.�--Susp. (Paddle) Pans
No. of Taut
ITransformers KVA
No. of Luminaire Outlets
3
a o.fHot T bl
No. dfHot Tabs
I Generators KVA
No. of Luminaires
Switumina p , —Above r-, In-
001
-No. ot Emergency Lig g
lRattery
omd. Emd
Un-ffi
No.of Recpptacle Outlets
No. of On Burners
'of 0" Burn
FIRE AJARMS No. of Zones
I
No. of Switches
No. ofGas Burners
No. of DetecfioF_and7----
No. of Ranges
Total
No. of Air Cond. T,'
'Initiating Devices
No. ofAlerdog Devices
No. of Waste Disposers
ons
ReaP7u_M7PNu r!1beriTons KW
au —I
Totals: I
JNo. of Self-contained
No. -of Dishwashers
Space/Arcia Heating KW
Sp
Detection/Alertina Devices
[I Imunt—dipal
17 Offier
Connection.
No. of Dryers
No. 'ater
'Local
ating pplh
41Heating Appliances KW
Security N tems:1
evices or
o
Heaters KW
(L 0.
(L 0 No.
-No-of ...... t
Ditto Wiring:
S. 5
S* 5 Ballasts
iEuivaient
No. of Devices or E 111valent
al
;Nn,
No. Hydromassage Rath
Total HP
. elecommunications * * .
ining,
of Devices or nuivaient
OTHER:
Attach additional derail i(desired, or as requi
-Estirriated Value of Electrical Work: _�500' Lk) (V*lh= required by municipal policy.)
Work'to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I NS`URANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue uhiess
tile 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 ermitissuirigof�ee,
LANCE 0 ROND 0 OTHER E] (Specify:) LibertyMutual
C1 IF-CKONE: INSUP p
I certtry' under the Pa'ns and Penaltics OfP-CriurY, that the information on this application is true and complete -
Fl IZAI NAME: K@yspaa Ugwo Ene- . gy S wyire, N F.. LLC LIC. NO.: 10128A
Licensee: RichuA.E_Qayer Signature LIC. NO.:
(1j'applicabic, enter " Ac__"&9�2 24L - -
A d d ress: =emPf " in the license number line.) v Ir Bus. TeL No.: 7-
V11U rL Alt. TeL No.:
U41Y
Per M.G.L. c. 147, sl"- t, se!c " - - - - * es epartment of Pubfic -Safety "S" License: Lic. No.
0 NAIN ERIS INSURANCE WAJVER: I am aware that the Licensee does not have the liability insurance coverage normally
reqUiredbylaw. Bymy signature below, I hereby waive this requirement, I amthe(check one) EJ owner 7n-ner'sazent.
Owner/Agent
Telephone No. PERMITf� �.�6j
if
all
41
am
Date. '?/� /.— !� !� . .
4, TOWN OF NORTH ANDOVER
0 -_-nab.
PERMIT FOR PLUMBING
x M--
4SA US
This certifies that ... ............. !
has permission to perform ..... 1P
...............................
plumbing in the buildings of 5"k. r . I ..............
at ....
North Andover, Mass.
Fee.3-4 Lic. No.. (—t—
....... ............... —:'� - — --------
U IVIBING INSPECTOR
Check # 4-046
=I
Q
INSURANCE COVERAGE:
I have a current liability insurance poll icy or Us substantial equivalent which meets the requirements of MGL. Ch. 142
If you have checkbd'Yyes, pie . ase indicate the type of coverage by checking the appropriate box below.
A liability indurairice policy 0 X Other type of indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter -142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Owner L3 Agent LJ
Agent
I -hereby certify that all of the details and Information I have submitted (or entered) regarding this application are true and accurate to the best of mv
nnowieoge ana that all plumbing work and Installations performed under the permit Issued for this application will be in compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By J Typ e of License:
Titlel 5_3 Plumber §6TFaTuie of-LicensedAum'berf
V RR'i7
master ED ..... . ..... ....... N�.
CltyfTowni , F-1. License Number: 1'2f __e457 fi,
APDOMICrIt fnmrlf�c I lec r%K11 V% Joumeyma
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
City/Town:j North Andover MA. Date: 1 2/23/09 :],Permit#
Building Location:1 01 Q alp;gla T-quprn .1 n Owners Name: r___XUrt Von Sneidem
P
Type of Occupancy: CommercialF� EducationaQ Industrial[] InstitutionalID Residential FIX
L_j
Now: El Alteration: Renovation:131" Replacement: Plans Submitted: Yeso No
INSURANCE COVERAGE:
I have a current liability insurance poll icy or Us substantial equivalent which meets the requirements of MGL. Ch. 142
If you have checkbd'Yyes, pie . ase indicate the type of coverage by checking the appropriate box below.
A liability indurairice policy 0 X Other type of indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter -142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Owner L3 Agent LJ
Agent
I -hereby certify that all of the details and Information I have submitted (or entered) regarding this application are true and accurate to the best of mv
nnowieoge ana that all plumbing work and Installations performed under the permit Issued for this application will be in compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By J Typ e of License:
Titlel 5_3 Plumber §6TFaTuie of-LicensedAum'berf
V RR'i7
master ED ..... . ..... ....... N�.
CltyfTowni , F-1. License Number: 1'2f __e457 fi,
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kuySpan tiume entagy Serviees
Chock
One, Only Certificate #
Installing Company Name:1
2262
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Corporation
Burlington
Address. -I 62 Se ond Avenue C4/Townl--- State: [:MDA
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Partnership
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Business Tot: 1 781-359:-2:630 Fax: 781-359-2745
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Finn/Company :3
Andrew T-Fre—ming
Name- of Licensed Plumber I
-
INSURANCE COVERAGE:
I have a current liability insurance poll icy or Us substantial equivalent which meets the requirements of MGL. Ch. 142
If you have checkbd'Yyes, pie . ase indicate the type of coverage by checking the appropriate box below.
A liability indurairice policy 0 X Other type of indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter -142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Owner L3 Agent LJ
Agent
I -hereby certify that all of the details and Information I have submitted (or entered) regarding this application are true and accurate to the best of mv
nnowieoge ana that all plumbing work and Installations performed under the permit Issued for this application will be in compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By J Typ e of License:
Titlel 5_3 Plumber §6TFaTuie of-LicensedAum'berf
V RR'i7
master ED ..... . ..... ....... N�.
CltyfTowni , F-1. License Number: 1'2f __e457 fi,
APDOMICrIt fnmrlf�c I lec r%K11 V% Joumeyma
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Date ... 3))
TOWN OF NORTHIANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that . . . .� / ?!'� � ..........................
has permission for gas installation #./3
......................
in the buildings of L/0 PV I j r 4 iv
.......... I .....................
at ... Nort h Andover, Mass.
Fee,;�T,.—. . Lic. No...3( ...... ........
GASINSPECTOR i
Check# 3-6/03
67'17
A—
INSURANCE COVERAGE:
1 h ' ay.e a current llablflty insurance pol . icy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes�,�Noll
If You have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy— X Other type of indemnity L LL]"
LJ 1 11, Bond
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Orwner Agent 71
Si natur nf Owner or Owner's Aaent L-4
By checking—t—his—b—ox-7; —1hereby certify that all of the details and information I have submitted (or entered) reqardina this aDolication arA trLip anrl
.1— — I .. . . .
— m, —y —1—muge ano inat aii plumoing work and installations performed under the permit issued for this application will be In
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
Type of License:
Byl
Plumber
Titiel Gas Fitter
Sirnature of Licensed PILYmber/Ga(s Fitter
Master MGF 3651
City/Town Journeyman License Number: i -
APPROVED (0FFlQE USE ONLY) LP Installer 31�
677
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town:1 North Andover Date; 1 2/23/09 �,"Permlt#!
Building Locafic,, Q'A Rgleig h Tavern T.n Owners Name:L��� Sneidern
Educational lndustrial7— Institutional[D Residentiall'
Type of Occupancy: CommercialD ID
171
New:7 Alteratiom RenovationO Replacement:,j Plans Submitted: Yes(j No �J,
INSURANCE COVERAGE:
1 h ' ay.e a current llablflty insurance pol . icy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes�,�Noll
If You have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy— X Other type of indemnity L LL]"
LJ 1 11, Bond
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Orwner Agent 71
Si natur nf Owner or Owner's Aaent L-4
By checking—t—his—b—ox-7; —1hereby certify that all of the details and information I have submitted (or entered) reqardina this aDolication arA trLip anrl
.1— — I .. . . .
— m, —y —1—muge ano inat aii plumoing work and installations performed under the permit issued for this application will be In
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
Type of License:
Byl
Plumber
Titiel Gas Fitter
Sirnature of Licensed PILYmber/Ga(s Fitter
Master MGF 3651
City/Town Journeyman License Number: i -
APPROVED (0FFlQE USE ONLY) LP Installer 31�
677
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BASEMENT
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3' FLOOR
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4 r
5 FLO- OR
6 FLOOR
7 FLOOR
8 FLOOR
rl..UySpan ticine, ffirmgy Sei viee.
Initalling Company Name:l-----
Check One Only - CbrtIfifjte4
Corporation
Ad dress. e co venue
Cityrrown A.State:FM-3A
:L- I
Partnership
Business Tel: 781-3 Fax:
Firrn�/Company
All 1 rig
Name of Licensed Plumher/Gas Fitter:F . . ... ... ....
INSURANCE COVERAGE:
1 h ' ay.e a current llablflty insurance pol . icy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes�,�Noll
If You have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy— X Other type of indemnity L LL]"
LJ 1 11, Bond
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Orwner Agent 71
Si natur nf Owner or Owner's Aaent L-4
By checking—t—his—b—ox-7; —1hereby certify that all of the details and information I have submitted (or entered) reqardina this aDolication arA trLip anrl
.1— — I .. . . .
— m, —y —1—muge ano inat aii plumoing work and installations performed under the permit issued for this application will be In
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
Type of License:
Byl
Plumber
Titiel Gas Fitter
Sirnature of Licensed PILYmber/Ga(s Fitter
Master MGF 3651
City/Town Journeyman License Number: i -
APPROVED (0FFlQE USE ONLY) LP Installer 31�
677
CA
I've
544 -
Dateh
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that
.........................................................................................
e -.n - M
has permission to perform ...........................
wiring in the building of ... I � '7'4 ..........................................
at ... //v N!4),Andover, M s.
...... .. ..
Fee ... Y� .......... Lic. ............... ELEc . m . ic _4.. �T�W . . ... .
Check# 1027
75� J-
1.
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No. 7,5- 7�
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: ?-iS-o-)
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) q3 P\e J;c�c
,_6_T
&4,e C, , I _
Owner or Tenant 0 (-CCJJ < �J Telephone No.
— 1�u , i
Owner's Address q1 - , 12 1
Is this permit in conjunction with a
Purpose of Building
permit? Yes E] No :g (Check Appropriate Box)
Existing Service A00 Amps /' LV VC) Volts
New Service Amps Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Utility Authorization No. 1W , J
OverheadEl Undgrd�5 No. of Meters
OverheadEl Undgrd [] No. of Meters
r� J�f;, L- -L1
Attach additional detail Y'desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: ;?— / 5- o *) 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 [I BOND 0 OTHERE] (Specify:)
I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete.
FIRM NAME: --A LIC. NO.: 31 _2
Licensee: Signature LIC. NO.: <leg g-.7 C:.
(If applicable, enter "exempt - in the license number line.) Bus. Tel. No.:
Address: _e,
7a2" - Ce d Alt. Tel. No.:
*Per M.G.L c. 147, s security work requires Department of Public Safety License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) E] owner Downer's agent.
Owner/Agent
Signature Telephone No. ---FPERMIT FEE.- $
uul� uL wai vea oy ine inspector ol wires.
No. of Recessed Luminaires
No. of Ceill.-Susp. (Paddle) Fans
No. �F Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming o In-
gency Lighting
grnd.
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
INo. of Zones
No. 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
.. . I
iNtim—ker.,
Tons-.
I . .
I KW
No. of Self -Contained
Totals:
-1
'
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local[] Municip�i E] other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No.
No. of Water
No. of --yo. —01
of Devices or Equivalent
Heaters KW
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wir!*ng:
No. of Devices or Equivalent
OTHER:
Attach additional detail Y'desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: ;?— / 5- o *) 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 [I BOND 0 OTHERE] (Specify:)
I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete.
FIRM NAME: --A LIC. NO.: 31 _2
Licensee: Signature LIC. NO.: <leg g-.7 C:.
(If applicable, enter "exempt - in the license number line.) Bus. Tel. No.:
Address: _e,
7a2" - Ce d Alt. Tel. No.:
*Per M.G.L c. 147, s security work requires Department of Public Safety License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) E] owner Downer's agent.
Owner/Agent
Signature Telephone No. ---FPERMIT FEE.- $
�,_4
I -r�
The Commonwealth ofMassachuselts
Department OfIndustrial Accidents
Office of In vesdgations
600 Washington Street
L11 Boston, ALI 02111
www-mass.govldia
workers' Compensadon Insurance Afridavit: Builders/Contractors/Electricians/Plumbers
DDlicaut Informatinn
Name (Business/Organizafion/Individual):
Address:
City/Statelip: Phone*
Are vou an P in 9 &-16
... r .7 W& cclL the appropriate box:
LEI I am a employer with — 4. 0 1 am a general contractor and I
[] employees (fidl and/or part-fim).*
2. 1 am a sole
have hired the sub -contractors
listed
proprietor or partner-
On the attached sheet
ship and have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers,
[No workers' comP. insurance
cOMP. insurance.t'
required.) -
3.E1 I am a homeowner doing
5. We are a corporation and its
Officers
all work
have exercised their
myself [No workers' comp.
right of exemption per MGL
insurance required.] t
C. 152, § 1(4), and we have no
employees. [No workers,
AnY aPPlicant that checks box #1
U.— Must also fill out the section below showing their w..4,,
Type Of Project (required):
6. C] New construction
7. [] Remodeling
8. C] Demolition
9. 0 Building addition
10 -El Electrical repairs or additions
I I -El Plumbing repairs or additions
12.E] Roof repairs
13.[] Other
nqmsation pohcy information.
wnffs -no submit this affidavit indicating 'ley are doing all work and 0M hire outside contractors must submit a new affidavit indicating such.
tContractofs that check this box must attached an additional sheet showing the name of the sub -c tractors
en'PloYees. If the sub -contractors have empio on and state whether or not those entities have
Yeest theY must Provide their workers' cOMP. Policy number.
am an employer th at is pro Viding workers I c0filpen sadon insu ran ce fo
informadoiL r my employee&
Below is the Policy andjob site
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address:
City/State/Zip:
Attach 2 copy of the workers, compensation Policy declaration page (showing --------------
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead the Policy number and expiration date).
fine up to S 1,500-00 and/or one-year imprisonmen4 as well as civil penalties in the to the imposition Of criminal Penalties of a
of up to $250-00 a day against the violator. Be advised that a c form of a STOP WORK ORDER and a fine
Investigati2ns of the DIA KOK in�umrance coveracre verifirati.- OPY Of this statement may be forwarded to the Office of
1 do "ereby cerdfY under . the Pains andpenaWs ofperjury that the informadon pr . ovided above is true and correct
0.1 ---
use
area, to
or town offlcial,
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. CitY/Town Clerk 4. Electrical Inspector 5. Pl11Mh;nn
6. Other
Contact Person:
Phone #:
In
P
Date.�r.5R��f..�� ...
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ......... -..z .. ......................
has permission to perform-..,.
. . ...................
wiring in the building of ..... ..........................................
at ....... ...... 7 North Andover, Mass.
Fee��..�? ............. Lic. No. .1 ... ........................... il .............................
ELEcrRICAVINSPECTOK
Check# zv':�7 z 11 61
7 4 1 0
k
I
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. �qli)
,? g
Occupancy and Fee Checked
I[Rev. 1/071 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORAM TION) Date: a 5-- 2
City or Town of. NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) �3 eltllJ ZAI--e—
Owner or Tenant
Owner's Address
Telephone No.
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 F1 Undgrd [J No. of Meters
New Service Amps Volts OverheadEl Undgrd F1 No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Completion of the.following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. or— Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above Ej In- 0
grnd. grnd.
No. of Emergency Lignting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
JNo. of Zones
No. 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
I Number
I Tons
. .. ..
KW
I
No. of Self -Contained
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local o Municippi El Other
Connection
No. of Dryers
Heating Appliances KW
Security Svstems:*
No. of Devices or Equivalent
No. of Water KW
No. o No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: 7 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 [:] OTHERE] (Specify:)
Icertify, under thepains andpenallies ofperjury, thalthe information on this application is true andcomplete.
FIRM NAME: /IY/) -7;1, C LIC. NO.:
Licensee: Z /9, � ell t!z Signature LIC. NO.:
(If applicable, enter "exempt " in the licenle number line.) Bus. Tel. No.: M�-
Address: 15— 13e11eotze,&.,., -1P " olf 5-5* Alt. Tel. No.: 9;?,V-
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage non-nally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) El owner [I owner's agent.
Owner/Agent
Signature Alit Telephone No. FPERMI T FEE.- $
/r,
The Commonwealth ofMassachusetts
Department ofIndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le2ibly
Name (Business/Organization/Individual): I(JIJ Y8, 7 il n-_ e � 2;�, C_
Address: If I?e-11
4,1_e
01��lf
City/State/Zip:A/a//Mc,,,� Rqr5' 44" Phone
Are you an employer? Check the appropriate box:
1. P I am a employer with 4. El I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2.0 1 am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance 5. El
required.]
3.0 1 am a homeowner doing all work
myself. [No workers' comp.
insurance required.] f
listed on the attached sheet. I
These sub -contractors have
workers' comp. insurance.
We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. El New construction
7. F� Remodeling
8. E] Demolition
9. E] Building addition
I OJJ Electrical repairs or additions
I I.[] Plumbing repairs or additions
12TJ Roof repairs
13.R Other
*Any applicant that checks box # I must also fill out the section below showing their workers' compensation policy information.
� Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy andjob site
information.
Insurance Company Name: (f
Policy # or Self -ins. Lic. FY619 / '3�,�, � Expiration Date:
JobSiteAddress: 1-1�1(IrIzAl
� e City/State/Zip: 161,IX Aw/l/tIn AV
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under t# ormation provided above is true and correct.
11 ,f pains andpenalties ofperjury that the inf
Phone #:
Official use only. Do not write in this area, to be completed by city or town officiaL
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
Date .....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
-5 Z 1,V.& 4ni S 7- 4 e -,-
This certifies that ............... 7-!e.. ...........................
has permission to perform ......... ;5�pt�.r .............. ./-0 .................
wiring in the building of ................. ........................................
at ...... 9 ... 3 ... A44/.... I N h Andover, Mass.
36'-' Io3177/1 !9q
Fee...................... Lic. No ........................ ........
Check 'j E'*c-r*RicAL INSPECTOR
7 5 7 4
S_\ Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
.4
Official Use Only
Permit No. 7 -5- 7
Occupancy and Fee Checked
I
,ev. 1/07] (leave blankl
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be perfortned in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PPJNT IN INK OR TYPE ALL INFORMA TION) Date: ?- 19-0 �)
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number)
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building pe—rnnit?
L r-,
Telephone No.
Yes No (Check Appropriate Box)
Purpose of Building �_e p e- &A v,, An Utility Authorization No.
ExistingService le?o Amps c9yO . /.;LoVolk Overhead Undgrd
New Service — Amps —Volts Overhead El Undgrd
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
No. of Meters I
No. of Meters
Completion of the following ble mav be waived hv the Insnector nf Wires
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Abo e
Swimming Pool El 'n -d. F�
grnd. grn
IN o. of Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of OU Burners
FIRE ALARMS
INo. of Zones
No. 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
in
Heat Pu pTNumber
Totals:
Tons
JKW
No. of Self -Contained,
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local El Municippl. E] other
Connection
No. of Dryers
Heating Apptiances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water
Heaters KW
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wir!"ng:
No. of Devices or Equivalent
OTHER:
Attach additional detail �fdesired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: S 0 c) (When required by municipal policy.)
WorktoStart: F- 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 [I BOND [-I OTHEREI (Specify:)
I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete.
FIRM NAME: !� T 1 4' 1 C dg IC Ie C 0,n!� 4 C& C_ ka—,_ LIC. NO.: P&
Licensee: 1:9-1)11 40 Signature LIC.NO.:
(If applicable, enter "exempt " in the license number line.) Bus. Tel. No.: q,);?- t-1 15 - L14 -ft
Address: A0 t!9e>J 4000 J jo t- 7'zo t.J I t1A P Alt. Tel. No.: 19 2 2 -51.:) -?2ey
*Per M.G.L c. 147, s. §,46 1, security work requires Department of Public -Safety " S" License: Lie. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one)EI owner El owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $
4 The Commonwealth ofMassachusetts
Department ofIndustrial Accidents
Office of Investigations
600 Washington Street
Boston, AM 02111
www-mass-govldia
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A-Piplicant Information Please Print Ledbly
NaMe (Businesstorganizatiowlndividual): . le , t A* I &I - - " __
__Lkor za4 L Q /N S
Address:_ 10
City/State/Zip: �L. M Phone#: (4 L
A ra L2j-
.rom an employerr Check me appropriate box:
1 am a employer with jO 4. 1 am 8 general contractor and I
2 E3 employees (full and/or part-time).
1 am a sole
have hired the sub -contractors
listed
proprietor or partner-
On the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers
[No workers' comp. insurance
;OMP- insurance.: *
required.]
3. 1 am a homeowner doing all work
5.L3 We are a corporation and its
Officers have exercised their
myselt [No workers' comp.
right of exemption per , MGL
insurance required.] t
c. 152, § 1(4), andwe have no
employees. [No workers'
COMP. insurance required.]
:Any applicant that checks box #1 mun also fill out the secti below A-- I
Type of project (requireft.
6. El New construction
7. E] Remodeling
8. Demolition
9. Building addition
109 Electrical repairs or additions
I 1 -0 Plumbing repairs or additions
12 -El Roof repairs
13.[] Other
11g WUMCM compensation policy infornation.
Homeowners who subrrdt this affidavit indicating they am doing all work and maw
tContractors that check this box must attached an additional sheet showing then hire outside contractors must submit a now affidavit indicating such.
employees. If the sub -contractors have e loye the name of the sub-contrsctors and state whether or not those entities have
mP es- they must provide their workers' cOMP, policy number.
am aR employer that isproviding workers, compens'oion Insurancefor my eMP10Yee& Below is thepolicy andjob site
informadom
Insurance Company Name: fr-)
Policy ff or Self -ins. Lic. #:
Job Site
C r-\- Lon
Expiration Date:
n1_1C_j0 I/ fv�_ P
Attach a copy of the workers9 compensation
(showing the policy number and expiration date).
Failure to secure coverage as. required under Section 25A of MGL c. 152 can le'ad to the imposition Of criminal penalties of a
fine up to $1,500.00 and/or one-year jmprisonmen� as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the office of
Investigations of the DIA for insU'rance nnuprarro
I do hereby cerVfy
OfPedurY that the informadon provided above is true and correcL
11!�? - : 0 _/ —
I . :1:2 tllll
Phone 4: - L( �) lot -111. 1 (/ a? I
. use on Don W-119 in In's area, to be co*l-etedby city or town offlciaL
City or Town:
Q 0
f
flc'
a' us,
or To
fficial
City Permit/License #
issuing Authority (circle one):
- I
1. Board of Health 2. Building Department 3. CitY/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. FOther
- - ---------
Contact Person: Phone #:
TOWN OF NORTH ANDOVER to
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT 41
19
1600 OSGOOD STREET BUILDfNG 20, STE. 2-64
NORTH ANDOVER. MASSACHUSETTS 01845 AC
Susan Y. Sawyer, REHS/RS
Public Health Director
April 27, 2007
Virginia & David Foulds
93 Raleigh Tavern Lane
North Andover, MA 01845
RE: Wastewater System Plan for 93 Raleigh Tavern Lane
Dear Mr. & Mrs. Foulds,
978.688.9540 — Phone
978.688.9542 — FAX
The North Andover Board of Health has completed review of the onsite wastewater treatment
and dispersal system design plans for the above referenced property submitted on your behalf by
New England Engineering Services dated February 7, 2007 and received by this office on
February 28, 2007 with supplemental material received on April 17, 2007.
The design has been approved for use in the construction of a replacement onsite wastewater
system. This approval is valid for three years from the date of this letter and during this time a
licensed septic system installer must obtain a permit and complete this work, and a Certificate of
Compliance must be endorsed by the installer, designer and the Town of North Andover. The
time period for which this plan is valid is reduced to two years from the date of an inspection of
the current wastewater system which did not meet the acceptable criteria in the state regulations.
The time period for which this plan is valid may be reduced by the North Andover Board of
Health in the event an imminent health problem such as sewage backup into the dwelling is
occurring.
This approval included the following variances that were approved at a regularly scheduled Board
of Health meeting on March 22, 2007.
Local QWrade Aomval
Allow the use of a sieve analysis to determine loading rate in lieu ofperforming a percolation test
Title 5, section 15.405(l).
Local &Law Variance
Reduction in offset distance between a leach bed and a wetlandfirom I 00feet required to 51 feet
This approval is subject to the following conditions:
i. The owner shall keep the attached form 9b for their records
2. If site conditions are found in the field to be different from those indicated on the design
plan and/or sod 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(l)),
3. It is the responsibility of the applicant and/or the applicant's designer, 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.
4. The approval letter issued by the Massachusetts Department of Environmental Protection
(DEP) for the treatment unit which is part of this onsite wastewater system requires:
a) "Operation and Maintenance Agreement: Throughout its fife, the Owner of the System
shall have the System properly operated and maintained in accordance with Company's
and designees operation and maintenance requirements and this Approval and be under an
operation and maintenance agreement (O&M). No O&M agreement shall be for less than
one year." Maintenance shall consist of observing the system and monitoring effluent
from the system at least semi-annually.
A signed maintenance agreement must be returned to this office prior to issuance of a
Disposal Systems Construction Permit. The maintenance agreement is to be for all the
components of the on-site wastewater system including the tank, treatment unit and soil
absorption system.
b) "The owner of the System shall record in the appropriate registry of deeds a notice that
discloses the existence of this Remedial Use approved alternative system. A copy of the
book and page number of the recording must be provided to the local approving authority
and the Department of Environmental Protection prior to the issuance of the Certificate of
Compliance."
c) The owner of the System shall provide a copy of the DEP Approval letter, prior to the
signing of a purchase and sale agreement for the facility served by the System or any
portion thereof, to the proposed new owner.
Your effort to provide a properly functioning onsite wastewater treatment and dispersal system
for your property is greatly appreciated. The Health Department may be reached at 978-688-
9540 with any questions you might have.
ZSincerel Z2
S/�_� .11
usan Y. Sawyer, IR
Public Health Director
encl: List of licensed installers
cc: New England Engineering Services
file
I
4 1
1IFF"ruffit
When filling out
liono onthe
computer, use
only the tab key
to move your
cursor - do not
toe the return
key.
�u
FimX
Commonwealth of Massachusetts
Cityrrown of
Local Upgrade Approval
Form 913
DEP has provided this form for use by local Boards of Health if they choose to do so.
The Local Upgrede Appmval is to be completed by the local Board of Health and a signed copy provided
to the system owner.
A. Facility Information
1. Facility Name and Address
David and Virginia Foulds
Nam
93 Raleigh Tavern Lane
Street Address
North Andover MA 01845
cityfrow State zip code
2. Owner Name and Address (if different from above):
Name
Cityffow
Zip Code
3. Type of Facility (check all that apply):
Z Residential El Institutional
4. Design flow per 310 CIVIR 15.203:
5. System Designer
1600 Osgood St
Address
B. Approval
Street Address
Telephone Number
0 Commercial El school
ff-1 51
gpd
Ben Osgood Jr. PE RS
Nam
North Andover 01845
cityrrow
1. Local Upgrade Approval is granted for
[I Reduction in setback(s) — specify:
Reduction in SAS area of up to 25%:
93 Raleigh Tavern form 9b 4.27.07 - rev. 7/06
SAS size, sq. ft.
State, ZIP
% reduction
Local Upgrade Appruvale Page I of I
Commonwealth of Massachusetts
City/Town of
Local Upgrade Approval
Fonn 913
B. Approval (continued)
[3 Reduction in separation between the SAS and high groundwater
Separation reduction
Percolation rate
Depth to groundwater
[I Relocation of water supply well (explain):
ft.
ffdn.Anch
ft.
C1 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
List local variances granted not requiring DEP approval per 310 CIVIR 15.412(4):
reduction in offset distance between a leach bed and a wetland from 100 ft to 51 feet.
List variances granted requiring DEP approval:
N. Andover Board of Healath
Approving Auftrily
Susan Sawyer, Health Director
PrInt or Type Norm wW We
93 Raleigh Tevem form 9b 4.27.07 - rev. 7/06
2007
Local Upgrade Approvale Page 2 of 2
TOWN OF NORTH ANDOVER t&01M1
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
1600 OSGOOD STREET BUILDING 20, STE. 2-64
NORTH ANDOVER, MASSACHUSETTS 0 1845
Susan Y. SalAyer. REHS/RS
Public Health Director
April 27, 2007
Virginia & David Foulds
93 Raleigh Tavern Lane
North Andover, MA 01845
RE: Wastewater System Plan for 93 Raleigh Tavern Lane
Dear Mr. & Mrs. Foulds,
978.688.9540 — Phone
978.688.9542 — FAX
The North Andover Board of Health has completed review of the onsite wastewater treatment
and dispersal system design plans for the above referenced property submitted on your behalf by
New England Engineering Services dated February 7, 2007 and received by this office on
February 28, 2007 with supplemental material received on April 17, 2007.
The design has been approved for use in the construction of a replacement onsite wastewater
system. This approval is valid for three years from the date of this letter and during this time a
licensed septic system installer must obtain a permit and complete this work, and a Certificate of
Compliance must be endorsed by the installer, designer and the Town of North Andover. The
time period for which this plan is valid is reduced to two years from the date of an inspection of
the current wastewater system which did not meet the acceptable criteria in the state regulations.
The time period for which this plan is valid may be reduced by the North Andover Board of
Health in the event an imminent health problem such as sewage backup into the dwelling is
YAIW-J, H-1
This approval included the following variances that were approved at a regularly scheduled Board
of Health meeting on March 22, 2007.
Local VRgade A
Allow the use of a sieve analysis to determine loading rate in lieu ofperfonning a percolation test.
Title 5, section 15.405(l).
Local Aylaw Variance
Reduction in offset distance between a leach bed and a wettandfrom 100feet required to 51feet.
This approval is subject to the following conditions:
1. The owner shall keep the attached form 9b for their records
2. 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(l)).
3. It is the responsibility of the applicant and/or the applicant's designer, 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,
Budding 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.
4. The approval letter issued by the Massachusetts Department of Environmental Protection
(DEP) for the treatment unit which is part of this onsite wastewater system requires:
a) "Operation and Maintenance Agreement: Throughout its fife, the Owner of the System
shall have the System properly operated and maintained in accordance with Company's
and designer's operation and maintenance requirements and this Approval and be under an
operation and maintenance agreement (O&M). No O&M agreement shall be for less than
one year." Maintenance shall consist of observing the system and monitoring effluent
from the system at least semi-annually.
A signed maintenance agreement must be returned to this office prior to issuance of a
Disposal Systems Construction Permit. The maintenance agreement is to be for all the
components of the on-site wastewater system including the tank, treatment unit and soil
absorption system.
b) "The owner of the System shall record in the appropriate registry of deeds a notice that
discloses the existence of this Remedial Use approved alternative system. A copy of the
book and page number of the recording must be provided to the local approving authority
and the Department of Environmental Protection prior to the issuance of the Certificate of
Compliance."
c) The owner of the System shall provide a copy of the DEP Approval letter, prior to the
signing of a purchase and sale agreement for the facility served by the System or any
portion thereof, to the proposed new owner.
Your effort to provide a properly functioning onsite wastewater treatment and dispersal system
for your property is greatly appreciated. The Health Department may be reached at 978-688-
9540 with any questions you might have.
ZSincerel Z2
S/�_� .
usawn Y. Sawyer, IR
Public Health Director
encl: List of licensed installers
cc: New England Engineering Services
file
.1
Commonwealth of Massachusetts
1=99999"M
gpvl�
69dM2ffiE= Cityrrown of
RINIF-1,M19
Local Upgrade Approval
Form 9B
DEP has provided this form for use by local Boards of Health if they choose to do so.
The Local Upgrade Approval is to be completed by the local Board of Health and a signed copy provided
to the system owner.
krworw*.
when filling out
fbmis on ft
cornputer, use
As Facility Information
I . Facility Name and Address
David and Virginia Foulds
orgy the tab key
Name
to move Your
93 Raleigh Tavern Lane
cursor - do not
use ft return
StreetAddress
key.
North Andover
MA 01845
CRyfTown
state Zip Code
2. Owner Name and Address (if different from above):
Narne
Street Address
CRY/Town
state
ZJp Code
Telephone Number
3. Type of Facility (check all that apply):
Residential Institutional commercial El school
4 Design flow npr nin (-up ir. in-ae "1W
5. System Designer
1600 Osgood St
Address
B. Approval
Wd
Ben Osgood Jr.
Narne PE RS
North Andover 01845
cityrrown State, ZIP
1. Local Upgrade Approval is granted for
0 Reduction in setback(s) — specify:
0 Reduction in SAS area of up to 25%:
93 Ra"h Tavern form 9b 4.77.07 - rev. 7/06
SAS size, sq. ft.
% reduction
Local Upgrade Approvals Page I of I
.1
Commonwealth of Massachusetts
Cityfrown of
Local Upgrade Approval
Form 913
B. Approval (continued)
El Reduction in separation between the SAS and high groundwater
Separation reduction
Percolation rate
Depth to groundwater
0 Relocation of water supply well (explain):
ft.
rrdn.Anch
ft.
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
List local variances granted not requiring DEP approval per 310 CIVIR 15.412(4):
reduction in offset distance between a leach bed and a wetland from 100 ft to 51 feet.
List variances granted requiring DEP approval:
N. Andover Board of Healath
Approft Aug"
Susan Sawyer, Health Director
Pfird or Type Nam and Trde
93 Raleigh Tavem form 9b 4.27-07 - rev. 7/06
23.2007
Local Upgrade Approval- Page 2 of 2
18 -MAY -OT 15:28 FROM-AMPROD T-255 P-01/03 F-TOZ
44 Commercial Strtet
Raynham, MA 02767
Telephone- (508) 880-0233 MAY 2 2 2007
FAX: (508) 880,7232 0
LTOWN -rH MD
E
J�T
H OF �JORTH ANDOVER
ALTH DCEpA 4
RTMENT
Fax Cover Sheet A E�W
TO: North Andover Board of Health DATE: 5/18/07
ATTN: Pam FAX#: 978-689-9542
FROM: Lauren D. Usilton
SLMJECT; TOTAL PAGES: (Including Cover)
Pam,
Following please find the Operations and Maintenance Agrmrnent for the Single Home FAST
sysum to be located at 93 Raleigh Tavern Lane in North Andover, MA. A
Pleaw let me know if you have any questions.
Thanks,
Lauren
6H
18 -MAY -07 15:28 FROM-JRENGPROD
%Vh,x&wa&o- 9m-a&n&2t, Lf&Wti7&V, YW-
T-255 P-02/03 F -78Z
44 COMMOMial StrGGt
Playnham. MA
02767
Tel: (508) 880-0233
INSPECTION AND TESTMQ AaREEMENT Fax: (508) 880-7232
Agreement entered into by and between Wastewater Treatment Services, Inc. (herein called WTS) and the
FAST* System OWNER (herein called OWNER) for the inspection by WTS of certain equipment of OWNER
which is described below.
Upon acceptance of this agreement at WTS's office, WTS will render the following services only:
Equipment will be inspected at least 2 times per year that this Agreement remains in effect with the first
inspections beginning . lien inspections will include:
1) Testing of the sludge depth in the septic tar&
2) Inspection, power testing and cleanheplace intake filter of the air blower.
3) hiVedion of the alarm system.
4) Inspect overall condition of FAST* System.
5) Notify OWNER of any problems encountered.
6) Service other than, routine maintenance will be billed at an hourly rate, plus travel and parts.
WTS shall notify the local Board of Health and Departmerit of Environmerttal Protection in writing within 24
hours of a system failure or slam event including corrective measures that have been taken.
OWNER will be billed standard WTS charges for any parts used in repairs or maintenance. Any additional labor
time will be billed to the OWNER at current labor rates of $78.00 per hour.
Emergency service between regular inspections will be provided at standard labor rates during normal business
hours; at time and one-half after 5:00 PM and on Samulays; and at double time on Sundays and holidays.
Emergency service charges will include a minimum four (4) hours of labor, plus standard WTS charges for parts,
plus mileage and travel charges. The annual rate includes routine maintenance, but does not include repairs -
required for damages caused by abuse, accident, theft, ads of third persons, forces of nature, or alterations made to
the equipment. WTS shall not be responsible for failure to render the agreed services if caused by strikes, labor
disputes, non-cooperation by OWNER, or other factors beyond the control of WTS.
OWNER understands and agws that W`lrS is not responsible for special, incidental or consequential damages,
including but not limited to loss of time, injury to person or property, or equipment failure.
OWNER agrees that WTS nay enter OWNER's property and have acceptable access to all areas deemed by
WTS to be necessary or appropriate for WTS to perform its duties hereunder.
Current WTS practice is to send OWNER approximately 10 days before expiration of the term of the current
contract (1) either a new contract or an offer to extend the current contmot's tern,4 and (2) an invoice for one year
of service. It is OWNEWs responsibility to timely return the payment and either the new contract or the accepted
extension, completed and signed. WTS must receive the payment and document before expiration of the then
current contract year to assure continuous contract coverage. Failure to return such documents on time or to
18 -MAY -07 15:26 FROM-AMPROD +15088607232 T-255 P-03/03 F-792
#" - t V
otherwise comply with this contract, may result in suspension Of service, cancellation of the contract and/or
nullification of warranties, at the election of WTS. OWNER may not assign this contract without the prior written
consent of WTS. it will remain in force until a party cancels by written notice to the other at the address given
herein, or until the contract term expires, whichever is sooner.
MANUFAC MODEL NO. SERIAL NO. LOC ANNUAL PE
Bio-Microbics MicroFAST North Andover, MA $400.00 Remedial
EQUIPMENT ffW—NER
*Signed by OWNER:
David Foulds
*Address:
93 Raleigh Tavern Lane
*City: State: - zip: —
North Andover MA 01945
Te I e phone -17 8 - 6 91 - 95 8 3
Daytime Telephone:
Includes (2) Field Tests
&astewater Treatment Services, Inc.
A#V
AW -
Signed:
44 Commercial Street
Raynham, MA 02767
Tele: (508) 890-0233
Fax: (508) 880-7232
Effective Date of Agreement
OWNER understands that (1) ANNUAL RATE payment is for one year only commencing on the effective date set
forth above and is non-refundable; and (2) Current DEP Regulations require OWNER to maintain a service
agreement for the life of the FAW System. I RAVE READ AND UNDERSTAND THE FOREGOING.
*Signed by OWNER:
Field Testing
Onsite testing performed twice per year will be used to demonstrate that the system ate operating at a sccondaTY
treatment standard of 30 mg/L of BOD5 and TSS. The following will be performed:
1) Visual examination of the effluent for color, turbidity and effluent solids.
2) Effluent pH to determine if the waste water is between 6 and 9 standard units.
3) Dissolved Oxygen, 2mg/L or more, to ensure that the system is operating.
4) Turbidity, less than or equal to 40 NTU-
If the effluent does not meet effluent quality standards, a grab ample will be collected for laboratory analysis.
Results sent to state and local Agencies as well as the OWNER. OWNER is responsible for providing acceptable
access to effluent for field testing and/or to enable a grab ample to be taken for laboratory testing performed. If
such laboratory sample is required, OWNER will be responsible for chugs incurred. IF REQUIRED, THE
COST FOR TMS ADDITIONAL TESTING WILL BE $180.00/VISIT.
*Approval for Additional Testing if Required,
Homeowner's Signature
Operator wiped: Willi2m Everett
Telephone: (5091400-3968 *Engineer: New England Engineering
0
Vav&watel- 91-w&wnt Jawe��, Yw.
August 23, 2007
North Andover Board of Health
1600 Osgood Street
North Andover, MA 0 1845
Attention: Board of Health Agent
Reference: Home FAST Treatment
Serial Number: 29725
44 Commercial Street
Raynham, MA
02767
Tel: (508) 886-0233
Fax: (508) 880-7232
R E C" L
SEP 6 2007
TOWN 07NC;�','-i P' )OVER
FEA-7,-iL�--
Attached please find a copy of the Product Registration Report for the �AS
F
System for the startup performed on at the home of David Foulds locat at 93 Raleigh
Tavern Lane, North Andover, MA. Also, attached is a copy of the fully e
Inspection & Testing Agreement.
If you have any questions or require additional information please do not hesitate to call.
Sincerely,
Donna L. Callahan
Enclosures
----------
Rr-
DER has prOVIded this form for use by local Boards of Health. The System" Puffi—p'ln'
"be Sub; tted to the.loCal'Board of Health or other approving autho Ity.
m g Record must
Ai Facility Inforniation SEE
TOWN OF
TH ANDOVER
hAortant: HEALTH EPART ENT
Wfiin* Mang' out Syst bon:
em Loca
on the,
COMPU I
, U34 Address
only the tab key
to move your -.1
�;.curw - do not
i"�: 'Use ereturn-:.- Tl�/Town
...... State Zip Code
y
iiam wner.,
Name - -
i :j
Address (it different
frorn location)
Ulty/T
own''
Zip Cod
State �2
97
Telephone Number
IPU
rd
'o
""IJ t 'fP g
a wo
u
2 Qu a*ntity Pumped:
Date
Gallons
�pp of, system:,.",; 0 CeSS0001(s) C3 Septic Tank
Tight Tank
ther escribe):
EMu'eht Tee Filter Oresint?. [I 'Yes
No' If yes, was it
cleaned? Yes EI.No
. .. .. .....
ys �T
fS 't,
7:
'71
ty,
:. y p
u
am
N
Vehicle Ucen*e Number
0
0
Co
re ontentswer dipposed:
7 L
ocd�h
Date
m*ass. oVIdep/,w p v4lj�tgc' s,
.9 rm htm#lnspect
ng,Re
MpIng','.
Dews
Date
3
t5fbmv4.doc�-06/0*
System Pumping Record Page 1 of 1
TOWN OF NORTH ANDOVER
Office of COMMUNITY DEVELOPMENT AND SERVICES
0
HEALTH DEPARTMENT
400 OSGOOD STREET X W
NORTH ANDOVER, MASSACHUSETTS 01845 A
978.688.9540 - Phone
Susan Y. Sawyer, REHS/RS 978.688.8476 - FAX
Public Healt4i Director E-MAIL: healthdeptAtownofnorthandover.com
WEBSITE: h!tp://www.townofnorthandover.com
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM - INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System (v(Constructed; ( ) repaired;
by
located at
j1C_
int Name)
Address)
was instal ed in conformance with the North Andover Board of Health approved plan, originally
dated and last Revised on g with a design flow of
Z! # 7/7
6Z/Z 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 3 10
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.
Bed inspection date: sliCAP-7
Final inspection date: Lg
,La.7
Installer:
And - Print Name 9
Engineer:
MUM Ill
And - Print N CIVIL
No.
.46891
IST
NA
Engineer Repre`s�niative &gnature)
n4� C Ay4jW k1i
And - Print Name
t6l 4"f* rD,2
Engineer Represent e (Signature)
—43 cc J-�_
And - Print Name
(Signature) Date: '9
(Signature) Date: -9
- 17L07
0
0
( r4W-W
PUBLIC HEALTH DEPARTMENT
(ommunity Development Division
%_' Aj
f YFRTI(FICATE OE C0914PLIANCE
As of-.
October 5, 2007
7his is to certify that the individualsu6surface d4osalsystem receiveda
SAq7SE,4CT0RT1YS(PECT10Yqf the:
Tuffy RepairedSeptic System
OY-11
Robert Da�qfi�
A t:
93 Wgre�yh Tavern Lane
Wap 107.,X; (Parce[116
Xorth_Xndover, M_A 01845
The Issuance of this certiftate shad not 6e construed as a guarantee that the system wid
-function satisfactofily.
4 an
S Sauyer
ft6fic Ifeafth Director
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
PUBLIC HEALTH DEPARTMENT
(ommunity Development Division
f YVRTIEIC
XqtF OE Coq�JPL T ONCE
.& .9-1 A.1 .
As of-.
October 5, 2007
qWis i to certify that the individua(su6surface d4osa(system receiveda
SgqjSE
,qCTORYINS(PECTIONof the:
Euffy We-pairedSeptic System
By.,
Robert Da�qfe
93 4Zofe�yh Tavem Lane
911ap 107.,A; (Parre1116
Xorth,4ndover, W,4 01845
The issuance of this certificate shad not 6e construed as a guarantee that the system wiff
function satisfactorify.
SLan T Sau�yer
ft6fic Yfealth Director
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com
TOWN OF NORTH ANDOVER Tm
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
400 OSGOOD STREET
C
NORTH ANDOVER, MASSACHUSETTS 0 1845 AC
978.688.9540 - Phone
Susan Y. Sawyer, REHS/RS 978.688.8476 - FAX
Public Health Director E-MAIL: healthdept(t�townofnorthandover.com
WEBSITE: hqp://www.town fnorthandover.com
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM - INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System
I (41constructed; repaired;
by
located at
S
int Name)
ion Address)
was in e with the North Andover Board of Health approved plan, originally
dated last Revised on with a design flow of
W-0 9/op 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 3 10
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.
Bed inspection date: A010-7
A -z
Efigineer Repres�niative (�ignature)
< AVL04 L/01
And - Print Name
Final inspection date: g_� (�- a 4?
Engineer Representafi've (Signature)
— _. cc
And - Print Name
Installer: (Signature) Date:
— 4�z —
And - Print Name V
Engineer: r_ — (Signature) Date: 1 7407-
And - Print N V
N 0.;J'S4 6"8 9 1
0 - %�
October 19, 2009
North Andover Board of Health
1600 Osgood Street
North Andover, MA 0 1845
Attention: Health Agent
44 Commercial Street
Raynham, MA
02767
Tel: (508) 880-0233
Fax: (508) 880-7232
R E C [E �vE D
OCT 2 7 2009
TOWN OF NORTH ANC)OVER
HEALTH DEP RTMENT
Reference: FAST@ Wastewater Treatment System - Serial Number: 29725
Attached please find the Field Inspection & Service Report with field test results for
services performed on 09/11/2009 at the property of Kurt von Sneidem located at 93
Raleigh Tavern Lane - North Andover, MA.
Please call if you have any questions or require additional information.
Sincerely,
C zza��c5zll-ezz�
Wastewater Treatment Services, Inc.
Service Department
Enclosures
Copy to:
Kurt von Sneidern
Massachusetts DEP
-1 ir - ---t
DISTAL PRESSURE FORM
Customer Name:
Address: -2
City: 117"IN-v4 State: A) 4-
44 Commercial Street
Raynham, MA
02767
Tel: (508) 880-0233
Fax: (508) 880-7232
Serial Number: -,-3
5;-I",w L ---q
Date: Time:' Technician Signature:
Comments:
,-)_r&
LlMassachusetts Department of Environmental Protection
Bureau of Resource Protection - Title 5
DEP Approved Inspection and O&M Form for Title 5 I/A
Treatment and Disposal Systems
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
A. Installation
Kurt von� Sneidern
Owner
93 Raleigh Tavern Lane
Facility Street Address
North Andover
City
Mailing address of owner, if different:
93 Raleiqh Tavern Lane
Street Address/PO Box:
North An1dover
City t
978-208rl 107 ext.
Telephone Number
MA
State
B. Authorized Service Provider
Wastewater Treatment Services, Inc.
O&M Firm
44 Commercial Street
Street Address
Raynharn MA
City State
508-880-0223 ext.
Telephone Number
David Koshiol
Certified Operator Name
i
01845
Zip
2976
Certification Number
C. Facility/System Information
29725 Bio-Microbics, Inc,
DEP ID Manufacturer ID
08/22/2007
Installation Date
Approva I Type: General Provisional
Seasonal Residence — used less than 6 mo./year:
D. Operating Information
09/11/2009
Inspection Date
13"
Sludge Le4
Start of Operation
0 Piloting
0 Yes
01845
Zip
02767
Zip
MicroFAST.5
Model Number
Remedial
No
HMO,
Previous Inspection Date
Pumping Recommended Yes No
DEPMicroFASTnew.doc - io/19/og Page I of 3
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Title 5
1
DEP Approved Inspection and O&M Form for Title 5 I/A
Treatment and Disposal Systems
11196
E. Field Testing
Field Inspection
Color: gray brown clear turbid
other (specify):
Odor: musty earthy moldy offensive turbid
Effluent Solids: Xno some
pH 7.0 SU DO 6.4 mg/L. Turbidity 5.5 NTU
6 to 9 2 or greater 40 or less
Should a' Remedial or General Use system fail the Field Testing, effluent samples shall be collected
per Staodard Methods and analyzed for BOD and TSS.
F. Sampling Information
Samples Taken Influent Effluent
Commercial systems or systems with a design flow of 2000 gpd and greater, and General Use
nitrogen reducing systems:
440
gpd
Parameters sampled: 0 pH BOD 0 CBOD TSS TN Other (list below)
Other 1 Other 2 Other 3
G. Inspection and Maintenance
i
Description of any maintenance performed since previous inspection and during this inspection
Cleaned Filter... Checked Splash Recycle, Checked Distal Pressure
Notes and Comments:
DEPMicroFASTnew.doc - io/19/og
Page 2 of 3
LlMassachusetts Department of Environmental Protection
Bureau of Resource Protection - Title 5
DEP Approved Inspection and O&M Form for Title 5 I/A
Treatment and Disposal Systems
11196
H. Certification
I certify:.l have inspected the sewage treatment and disposal system at the address above, have
conducted the required Field Testing and/or sample collection in accordance with Standard Methods,
have completed this report and the attached technology operation and maintenance checklist, and
the information reported is true, accurate, and complete as of the time of the inspection. I am a
Massachusetts certified operator in accordance with 257 CMR 2.00.
David Koshiol
Operator Signature
09/11/2009
Date
System ' owner must submit this report, technology O&M checklist, and any required sampling results
to the local board of health and DEP as follows for each inspection performed:
Remedial Use — by January 31s'of each year for the previous calendar year
Piloting Use — within 45 days of inspection date
Provisional Use — by March 31 st of each year for the previous 12 months
General Use — by September 30th of each year for the previous 12 months
I
Send to:
Department of Environmental Protection
Attention: Title 5 Program
One Winter Street, 6 th Floor
Boston,,MA 02108
DEPMicroFASTnew.doc - lo/19/og Page 3 of 3
8450 Cole Parkway m Shawnee, KS 66227 w Phone 913-422-0707 u; Fax: 912-422-0808 11196
e-mail: onsite(cDbiomicrobics.com m www.biomicrobics.com m 800-753-FAST(3278)
FIELD INSPECTION & SERVICE REPORT
For Bio-Microbics Single Home FAST9 System
INSTALLATION
AUTHORIZED SERVICE PROVIDER
93 Raleigh Tavern Lane
Installation Address: NorthAndover,MA 01845
Name: Wastewater Treatment Services, Inc.
Owner Name: Kurt von Sneidern
Mail Address:
93 Raleigh Tavern Lane
NorthAndover,MA 01845
Mail Address: 44 Cornmercial Street
Raynham, MA 02767
city State Zip
Phone: 978-208-1107 Fax e-mail
508-880-0233 508-880-7232
Phone Fax e-mail
INSTALLATION INFORMATION
Model No. Serial No.
Date of Installation
Date of last pump out
MicroFAST.5 29725
08/22/2007
EQUIPMENT YES NO
MAfNTENANCE PERFORMED AND COMMENTS
Electrical Panel(s)
Visual Alarm Operating X
Audio Alarm Operating X
(if present)
Blower(s)
Air Inlet Filter Clean X
Blower Hood Vents Clear X
Excessive Noise X
Excessive Vibration X
Treatment unit(s)
Unusual Odor
Pumpout Required: X
Primary Settling Zone
13"
Aerobic Treatment Zone
15"
EFFLUENT (option�l) LIMIT RESULT
Estimated Daily Flow
440 gpd.
pH (Standard Units)
Color Clear
Temperature 68.9
Odor Earthy
Comments:
TECHNICIAN SERVICE DATE
David Koshiol 09/11/2009
, -.z
February 13, 2009
North Andover Board of Health
1600 Osgood Street
NorthAndover,MA 01845
Attention: Health Agent
44 Commercial Street
Raynham, MA
02767
Tel: (508) 880-0233
Fax: (508) 880-7232
RECEIVED
FEB 2 3 2009
TOWN OF r
HEALTH
Reference: FASTO Wastewater Treatment System - Serial Number: 29725
Attached please find the Field Inspection & Service Report with field test results for
services performed on 02/05/2009 at the property of Kurt von Sneidern located at 93
Raleigh Tavern Lane - North Andover, MA.
Please call if you have any questions or require additional infannation.
Sincerely,
AIZ��
Wastewater Treatment Services, Inc.
Service Department
Enclosures
Copy to: Kurt von Sneidern
Massachusetts DEP
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Title 5
DEP Approved Inspection and O&M Form for Title 5 I/A
Treatment and Disposal Systems 11196
B. Authorized Service Provider
Wastewater Treatment Services, Inc.
&M Firm
44 Commercial Street
Street Address
Raynharn MA
City State
508-880-0223 ext.
Telephone Number
David Zavelle
Certified Operator Name
12920
Certification Number
C. Facility/System Information
29725 Bio-Microbics, Inc.
DEP ID Manufacturer ID
08/22/2007
installation Date Start of Operation
Approval Type: General Provisional Piloting
Seasonal Residence — used less than 6 mo./year: Yes
D. Operating Information
02/05/2009
-Fn-spection Date
ludoe Level
DEPMicroFASTnew.doc - 2/13/09
01845
Zip
02767
Zip
MicroFAST .5
Model Number
X Remedial
M Z
Previous Inspection Date
Pumping Recommended Yes No
Page 1 of 3
A. Installation
Important:
Kurt von Sneidern
When filling out
Owner
forms on the
computer, use
93 Raleigh Tavern Lane
only the tab key
Facility Street Address
to move your
North Andover 01845
cursor - do not
City Zip
use the return
key.
Mailing address of owner, if different:
93 Raleigh Tavern Lane
Street Address/PO Box:
North Andover MA
City State
978-208-1107 ext.
Telephone Number
B. Authorized Service Provider
Wastewater Treatment Services, Inc.
&M Firm
44 Commercial Street
Street Address
Raynharn MA
City State
508-880-0223 ext.
Telephone Number
David Zavelle
Certified Operator Name
12920
Certification Number
C. Facility/System Information
29725 Bio-Microbics, Inc.
DEP ID Manufacturer ID
08/22/2007
installation Date Start of Operation
Approval Type: General Provisional Piloting
Seasonal Residence — used less than 6 mo./year: Yes
D. Operating Information
02/05/2009
-Fn-spection Date
ludoe Level
DEPMicroFASTnew.doc - 2/13/09
01845
Zip
02767
Zip
MicroFAST .5
Model Number
X Remedial
M Z
Previous Inspection Date
Pumping Recommended Yes No
Page 1 of 3
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Title 5
Lll�i DEP Approved Inspection and O&M Form for Title 5 I/A
I re im i a d Dispos I Syst ms
11196
E. Field Testing
Field Inspection
Color: gray brown clear turbid
other (specify):
Odor: musty earthy moldy offensive turbid
Effluent Solids: no some
pH 7.0 SU DO 6.53 mg/L. Turbidity 5.92 NTU
6 to 9 2 or greater 40 or less
Should a Remedial or General Use system fail the Field Testing, effluent samples shall be collected
per Standard Methods and analyzed for BOD and TSS.
F. Sampling Information
Samples Taken n Influent 0 Effluent
Commercial systems or systems with a design flow of 2000 gpd and greater, and General Use
nitrogen reducing systems:
440
SM
Parameters sampled: OpH OBOD OCBOD OTSS OTN 0 Other (list below)
Other 1 Other 2 Other 3
G. Inspection and Maintenance
Description of any maintenance performed since previous inspection and during this inspection
Cleaned Filter, , , Checked Splash Recycle,
Notes and Comments:
DEPMicroFASTnew.doc - 2/13/09 Page 2 of 3
Massachusetts Department of Environmental Protection
LlBureau of Resource Protection - Title 5
DEP Approved Inspection and O&M Form for Title 5 I/A
Treatment and Disposal Systems
11196
H. Certification
I certify: I have inspected the sewage treatment and disposal system at the address above, have
conducted the required Field Testing and/or sample collection in accordance with Standard Methods,
have completed this report and the attached technology operation and maintenance checklist, and
the information reported is true, accurate, and complete as of the time of the inspection. I am a
Massachusetts certified operator in accordance with 257 CMR 2.00.
David Zavelle
Operator Signature
02/05/2009
Date
System owner must submit this report, technology O&M checklist, and any required sampling results
to the local board of health and DEP as follows for each inspection performed:
Remedial Use —by January 31 st of each year for the previous calendar year
Piloting Use — within 45 days of inspection date
Provisional Use — by March 31't of each year for the previous 12 months
General Use — by September 30th of each year for the previous 12 months
Send to:
Department of Environmental Protection
Attention: Title 5 Program
One Winter Street, 6 th Floor
Boston, MA 02108
DEPMicroFASTnew.doc - 2/13/09 Page 3 of 3
.Oi� , 4.
I
B10., X'.N
8450 Cole Parkway m Shawnee, KS 66227 m Phone 913-422-0707 m Fax: 912-422-0808 11196
e-mail: onsite(cDbiomicrobics.com m www.biomicrobics.com ru 800-753-FAST(3278)
FIELD INSPECTION & SERVICE REPORT
For Bio-Microbics Single Home FAST9 System
INSTALLATION
AUTHORIZED SERVICE PROVIDER
93 Raleigh Tavern Lane
Installation Address: NorthAndover,MA 01845
Name: Wastewater Treatment Services, Inc.
Owner Name: Kurt von Sneidern
I
Mail Address:
93 Raleigh Tavern Lane
NorthAndover,MA 01845
Mail Address: 44 Commercial Street
Raynham, MA 02767
City State Zip
Phone: 978-208-1107 Fax e-mail
508-880-0233 508-880-7232
Phone Fax e-mail
INSTALLATION INFORMATION
Model No. Serial No. Date of Installation _F
-Date of last pump out
MicroFAST.5 29725 08/22/2007
EQUIPMENT YES NO MAINTENANCE PERFORMED AND COMMENTS
Electrical Panel(s)
Visual Alarm Operating X
Audio Alarm Operating X
(if present)
Blower(s)
Air Inlet Filter Clean X
Blower Hood Vents Clear X
Excessive Noise X
Excessive Vibration X
Treatment unit(s)
Unusual Odor
Pumpout Required: X
Primary Settling Zone
Aerobic Treatment Zone
EFFLUENT (optional) LIMIT RESULT
Estimated Daily Flow 440 gpd.
pH (Standard Units)
Color Clear
Temperature 43.0
Odor Earthy
Comments:
TECHNICIAN
SERVICE DA
David Zavelle
02/05/2009
1'r-
.1
September 22, 2008
North Andover Board of Health
Building 20, Unit 2 - 36
1600 Osgood Street
North Andover, MA 0 1845
Attention: Health Agent
44 Commercial Street
Raynham, MA
02767
Tel: (508) 880-0233
Fax: (508) 880-7232
LSEP 2 5 2008
TOWN OF NO" --R
W
HEALTH jL
Reference: FASTO Wastewater Treatment System - Serial Number: 29725
Attached please find the Field Inspection & Service Report with field test results for
services performed on 08/14/2008 at the property of Kurt von Sneidem located at 93
Raleigh Tavern Lane - North Andover, MA.
Please call if you have any questions or require additional information.
Sincerely,
A�1. m� � 6 Z �- � c 5- �
Wastewater Treatment Services, Inc.
Service Department
Enclosures
Copy to: Kurt von Sneidern
Massachusetts DEP
44 Commercial Street
Raynham, MA
02767
Tel: (508) 880-0233
Fax: (508) 880-7232
DISTAL PRESSURE FORM
r -
Customer Name: U Serial Number:
Address:— 7.3 gktt�CH
City: AL)pv�nc State:—Z�19
e ,
Date: Time: �31f' Technician Signature:
Comments:
Ll..Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Title 5
DEP Approved Inspection and O&M Form for Title 5 I/A
Treatment and Disposal Systems
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VQ
9394
A. Installation
Kurt von Sneidern
Owner
93 Raleigh Tavern Lane
Facility Street Address
North Andover
City
Mailing address of owner, if different:
93 Raleigh Tavern Lane
Street Address/PO Box:
North Andover
MA
City State
978-208-1107 ext.
Telephone Number
B. Authorized Service Provider
Wastewater Treatment Services, Inc.
01845
Zip
01845
Zip
O&M Firm
44 Commercial Street
Street Address
Ravnham MA 02767
City State
508-880-0223 ext.
Telephone Number
David Koshiol
Certified Operator Name
C. Facility/System Information
29725
DEP ID
92
2976
Certification Number
Bio-Microbics, Inc. MicroFAST.5
Manufacturer 10 Model Number
08/22/2007
Installation Date Start of Operation
Approval Type: General Provisional Piloting Remedial
Seasonal Residence — used less than 6 mo./year: Yes No
D. Operating Information
08/14/2008
Inspection Date
61,
Sludge Level
Previous Inspection Date
Pumping Recommended 0 Yes XNo
DEPMicroFASTnew.doc - 9/22/08 Page 1 of 3
Ll-,Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Title 5
DEP Approved Inspection and O&M Form for Title 5 I/A
Treatment and Disposal Systems
9394
E. Field Testing
Field Inspection
Color: gray 0 brown clear turbid
other (specify):
Odor: musty 9 earthy moldy offensive turbid
Effluent Solids: Ono nsome
pH 7.0 SU DO 5.82 mg/L. Turbidity 58.2 NTU
6to9 2 or greater 40 or less
Should a Remedial or General Use system fail the Field Testing, effluent samples shall be collected
per Standard Methods and analyzed for BOD and TSS.
F. Sampling Information
Samples Taken 0 influent n Effluent
Commercial systems or systems with a design flow of 2000 gpd and greater, and General Use
nitrogen reducing systems:
440
gpd
Parameters sampled: 0 pH 0 BOD 0 CBOD 0 TSS n TN 0 Other (list below)
Other 1
Other 2
Other 3
G. Inspection and Maintenance
Description of any maintenance performed since previous inspection and during this inspection
Cleaned Filter... Checked Splash Recycle,
Notes and Comments:
DEPMicroFASTnew.doc - 9/22/08 Page 2 of 3
Ll'Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Title 5
DEP Approved Inspection and O&M Form for Title 5 I/A
Treatment and Disposal Systems
9394
H. Certification
I certify: I have inspected the sewage treatment and disposal system at the address above, have
conducted the required Field Testing and/or sample collection in accordance with Standard Methods,
have completed this report and the attached technology operation and maintenance checklist, and
the information reported is true, accurate, and complete as of the time of the inspection. I am a
Massachusetts certified operator in accordance with 257 CMR 2.00.
David Koshiol
Operator Signature
08/14/2008
Date
System owner must submit this report, technology O&M checklist, and any required sampling results
to the local board of health and DEP as follows for each inspection performed:
Remedial Use — by January 31 s' of each year for the previous calendar year
Piloting Use — within 45 days of inspection date
Provisional Use — by March 31s' of each year for the previous 12 months
General Use — by September 30th of each year for the previous 12 months
Send to:
Department of Environmental Protection
Attention: Title 5 Program
One Winter Street, 6 th Floor
Boston, MA 02108
DEPMicroFASTnew.doc - 9/22/08 Page 3 of 3
9.11tz, N C 0 R P 0 A A T E D
8450 Cole Parkway w Shawnee, KS 66227 w Phone 913-422-0707 m Fax: 912-422-0808 9394
e-mail: onsite(cDbiomicrobics.com ta www.biomicrobics.com w 800-753-FAST(3278)
FIELD INSPECTION & SERVICE REPORT
For Bio-Microbics Single Home FASTV System
INSTALLATION
AUTHORIZED SERVICE PROVIDER
93 Raleigh Tavern Lane
Installation Address: NorthAndover,MA 01845
Name: Wastewater Treatment Services, Inc,
Owner Name: Kurt von Sneidern
Mail Address:
93 Raleigh Tavern Lane
NorthAndover,MA 01845
Mail Address: 44 Commercial Street
Raynham, MA 02767
City State Zip
Phone: 978-208-1107 Fax e-mail
508-880-0233 508-880-7232
Phone Fax e-mail
INSTALLATION INFORMATION
Model No. Serial No.
Date of Installation Date of last pump out
MicroFAST.5 29725
08/22/2007
EQUIPMENT YES NO
MAWTENANCE PERFORMED AND COMMENTS
Electrical Panel(s)
Visual Alarm Operating X
Audio Alarm Operating X
(if present)
Blower(s)
Air Inlet Filter Clean X
Blower Hood Vents Clear X
Excessive Noise X
Excessive Vibration X
Treatment unit(s)
Unusual Odor X
Pumpout Required: X
Primary Settling Zone
6"
Aerobic Treatment Zone
12"
EFFLUENT (optional) LIMIT RESULT
Estimated Daily Flow
440 gpd.
pH (Standard Units)
Color Turbid
Temperature 72.9
Odor Earthy
Comments:
TECHNICIAN SERVICE DATE
David Koshiol 08/14/2008
j U I 4b du Ut 11:Ud L.Mmnl,�V� j3UIL-Lir-Ma 0100011-001
10: 39 9786913i476
HEALTH
PAGE
14:02 FROM410GROD 02/03
F -M
44 CoMnwclal SOW
R30111M. MA
02757
-C
.
ASM - "W" CQtCr§d iM by and bOtwOen Walftwabr Tr4atimilt gerVI"th ISO h
a . (bgrdn Caod " and t e
"A" SM'00%"ZR(hfftlncanedoWMR)f"OwirAPOdOnbYVMofcaUbequipuifttof GWNSR
wWgh is deuribed. below.
TIPOU "GOPURIM of dus amment at WTS's office, W" will rador the fbllow4 savices only-
P,qui"It will be lD3PeFte4 lit least 2 thas; per y"r dat tW8 Agcmmt Mmabs In gfi
iMpeWom begicning 0 lWage laqwetia" will ilaclMe. =t, wtb the am
I ) Tgftg Of the 21U4V deplh in the septW tak,
23 kM"1i*k POWU MORS and clean/relplace intwo filM bf the air blower.
3) tupection of tho &lam syston.
4) WPM Overall condition of FAsjv,8y&%M.
5) NctifY OWhTA of anypable= encomtcra
6) SCIMCC other than routine Waintermce will be billed at &a howly fatal Igus tMVCj ad Pau.
"I Boud ArUcatb &nd D"artment of fiA*"r=W PmWd1O8 im writing wift 24
WTS sba Doti f� the 1*'
hour$ Of 2 SWOM follure or Warm emt iMIUAfial, corree" measurn that boyc bom t&kcm
OWM will be billed a%ndad'WTS cb&rg" ftw any part$ used in rep�a
time will be billed to the OVrMR at current labor Mtes of MOO per bour. or amiattuance. Any additional labor
Emeff9vacY savice between regular inqmdons will be pmMed at standwd I
houn; at fim ad ord-half &ft 5:00 PM W On 112tutdAYI; and a double
tim an sundqs aud hWlCUY&
F'=:McBW @eMce chuges will hwlude A Minimufft four (4) houn of labor, Plus standard WrS chatM for pats,
Plug MOM& Md vaVel cbarge3. Jim mmu&l fttc includes tOutific uWatenaeft, but does not keludg repain
reqUired for damaps cVMW by abot, accideggo, *4 acts of third pawas, fmes ofnaun, or 61*100" ME& to
dle equipmM WTS &hAU 'M be reVmli'We fir ftflure to render do agreed 'Wifts if eased by sirams, Igbor
d"4*2, mft-cOoPeration by OVMM Of Otbat &ctm beyand Ae eontml qfWTS.
0WNJ* underGUMU and ogre= th&tWrS in not responsible rWq*W&L jWden 0
including %&t not I*KW to hm of 1�
=w, pjwy to pemn tal r m1equentisl d&=ges,
or properex or Oquiptum fallum.
OWNM apees fut W1,15 May enter Ov6zlvs , , ,
prVerty MrA h&v'e "Ce"'ble access tQ 41 w0is deemed by
WTS to be SWCe"WY or 3"Prste '6r WTS to V91M iM dutias hftminder.
CUrMt WT3 praclice is to Send OWN= appro;d=rely
Cidw a new Contract or *a 10 days WOM exPiradon ofthe tma of the cwrent
Offer to extend the emmi eoutt4at,* Wr4 aW (2) an Invoice for one year
of IftVicc. It is 0WWR'S respossibiw to timely remm the paymm and Citha 60 r4w Contmat at tte
"fts'M eftVletrd and 111ped. WTS n= receive ft Psynmt and Accepicd
'lWft4 conUut year to ossurg cactinuoue amtMet CM d0cumm belbre expiration of he then
MM,e. Flilure 10 MUM such docurnents M *W of to
Jul 26 2UU7 11:Uj UKLHIIVt
'086'888476
' 24 -PAY -U 14:03 FROM -MGM
bUiLUtKb f fz$oi
HEALTH
PAGE 03/03
oftrwise comply with this coaftot, inzy mult in axpstasion of sorvice. omcalIation of 6e Cotntract and/of
nullification of warranties, st the election of WTS. OWN= rim not "on ft Mairsot widmt die prior wftm
consent of WTS. It will rcstain in &r= undl, A. pam owels by wrimn notice to ft edw ag ft addms gim
heeK or MbI the Contra" UM CapirM4 vwchever is goonor.
MAW&=MM hMMLM SEML WO, LOCAM "IAU MM
Bio-Microbies M1cMFAST df 7dj' North Andover, DAA $400.00 Rmedlat
Mudso 0) Pi old Testr
it OVVNE)a Trojamt SMIUL
*Sisne4 by Ounv" -
David Foulds INIA 4
*Addresm
93 Rate* ravern Lane
$City: State: — Zip: -�
Nofth Andava MA 01945
DqdTne Tdepbonc,-.
44 Corfulm id Sum
Pisahmn, MA 02767
Tole; (M) 180-0233
FOL; (508) 880-7232
Wadve Dais of ASM=Vmt..L- oew.-: j 7
OWNER wdnUWs ft (1) ANNUAL PATE payment is for fte yetz only awmencing on tte effective date gel
*"1h above and is nm-ref%ndable; and (2) Cmnt DEP RegWaftow nquin 0VjM to mdnt&in a MrAac
WMMUt (Or the life of fbC VA7wr em I RAVE READ AND UNDERSTAND THE ]FOREGOING.
*Signed by OWNEL.
6181te "StinS paftrard twice por yea will be used to dealOmtrate that the systm am operati-ag a a sacendary
lard Of 30 MS& OMODS WA TSS, The fbllowin$ will be perftmed:
1) ViS041 cumhud= 0fdo cfflum forcolor, turbidity sad einueot solids.
2) EMU= pK to deternine if U%o waste water is between 6 ad 9 standard miks.
X) Diwahvd Oxygen, 2rn&j or mom, to an$= *It tha jyggrn is epenft
if 4) Turbidity, less than or eqW to 40 NTLY.
'be efflucAt 4M not MM MUM quality SM&Ms, a gab ss*c w1a be collecied for laborwry ambWs.
Resulu sent to state "d 10CA1 ASOcias " well As the OVVM OWNER is responsible for Providing =npiable,
access to emem for field ItettimS andVor to enablo a 1pb ample to be takm for laborafty tesft perfame& if
Suct laboratory 3V*9 is requir*4 OVMlt vjill to zt*oftbk fm 4aVes inamed. IFREQUUMDDTU
COST FOR TMS ADDMONAL WSTMG WILL BE $280 00"IT.
Addiflow Testifty
Town Requ—h=njS We tgg 0 1 Sure one (1) dree pa, year It a cost of V 50-00A661.
*Approval for Top
monzeow-�ncr S Signaft"
opamtor assiped; WONAM jr-Y @no
Tdoplione; *Zu&ftr: Now England Englmcing