The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 97 GRANVILLE LANE 4/30/2018 (3)4 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts City/Town of System Pumping Record NORTH ANDOVE Form 4 RECEIVED JUL -1 9 2913 TOWN Of. NORTH°ANDOVER• H EALTHI t31;PPARTIVISNT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information 1. System/ �(Locaatiam te 7 `� Tr&A L.)/ ` V` R_ f C", "� Address City/Town State Zip Code 2. System Owner: Name -- f Co Address (if different from City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Gallons 90 Yale 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): -"-------- -----" 4. Effluent Tee Filter present? ❑ Yes V�,No If yes, was it cleaned? ❑ Yes P(No 5. Condition of System: 6. System Pumped By: --J-- M�� Name vi `d Company 7. Location where contents were disposed: of Receiving Facility t5form4.doc• 03/06 Vehic License Number I. /�W.WiT P. Date Date System Pumping Record • Page 1 of 1 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. ierim ' Commonwealth of Massachusetts City/Town of NORTH ANDOVER, System Pumping Record Form 4 MASSACHUSETT DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approvin au VCEIVE p I A. Facility Information JAN 1 0 2008 1. System Location: 0 TOWrN _<<- iVORTH ANDOVER L z-/ Kp(y� �� e HEALTH DEPARTMENT Address hl Iq hcl o ver/ City/Town State Zip Code 2. System Owner: Name Address (if different from location) City/Town State Zip Code 5?S.&.S'-7�K1 Telephone Number B. Pumping Record 1. Date of Pumping Dated 2. Quantity Pumped: Gallo 5 fo 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): — 4. Effluent Tee Filter present? ❑ Yes [-No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: Goo 6. SystPumped By: wo 3 _ H q- (0,o ;1- �1 Name Vehicle License Number Company 7. Location where contents were disposed: �w � >a Signature of Hauler Date http://www.mass.gov/dep/water/app,rovals/t5forms.htm#inspect t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Location No. LSA Date MORTM. TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame /Frame Permit Fee $ s�cHust 9 Foundation Permit Fee $ Other Permit Fee TOTAL Check # 287.58 $ L0::V'Q `Building Inswctor of TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVAT&2 OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED. SIGNATURE: /L44� Building Commissi2EAINector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: � _ � )V 1.2 Assessors Map and Parcel Number: Map Number Parcel Number / 1.3 Zoning Information: Zoning Distrid Proposed Use 1.4 Property Dimensions: Lot Area Fronto ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 We. Supply M.G.L.C.40. 54) Public ❑ Private 0 1.5. Flood Zone Information: Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHM/AUTHORIZED AGENT Historic District: Yes No 2.1 Owner of Record are (Print) (� Address for Service 7 `7Z l `_�j(J Sig�naturm Telephone 2.2 Owner of Record: H �(�K6:AGJ?:oy(c, Name Print Address for Service: Si ture Tele hone SEI's'TION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable D Company Name Registration Number Address Expiration Date Signature Telephone 00 rn X 3 Z O O Z M go O M r r z G) SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check as applicable) New Construction 0 Existing Building ❑ Repair(s) 0 Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Briel f DCription of Proposed Work: Fn eg E Z� 1z / 1\1 T W a SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed bV permit applicant bFFICIAL?TSEE+Ih.Y . . I . Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) GO 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 pQ Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ZI, t' C7 as Owner/Authorized Agent of subject property Hereby authorize to act on My a , inall m tters r tive to work authorized by this building permit applicati / Si tune of Owner Date ( RC2 SECTION 7b OWNER/A 1JTVrnR117rD AGENT DECLARATION I, ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB 71 SIZE OF FLOOR TMERS iST2 ND3 RD SPAN DR%dENSIONS OF SILLS DIN ENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHDANEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE rJ ■- CA m X X m N v m U 0 y d C � CA CD n Z y 06 ? O CL y 0 c v CD CDCL O Q =r CD CD O CD C CDCD y� 0 CA O I CC CD F v CA O 1 Z CD � CD CD0 C CD t p cn V J n O cn a] r mp C O C_?� O 01 Z d'�m ti y Mg Joao m n CA O CL ...F C �. S �o N mGO aid > y IE O m a O G C13 =r =.m 'a N a � � gm CL oma? - O O N 71 C7* . CL m h „�,• d y CL =r cr N C 0D n O CN CA O m Im CA to O n Cc, CD mo' G 33 H � O m Wim: D1 �' CD =-00 =0 CL r 0 0; CA c CA 5 °�- (n j z O a1 Cy tri ' 17 7 �'- JC7 O � �r1 O �' 7� n. ro "� O T CrJ tr9 t �7 O °'- 'Jd O 00 � bro z � °'- n � p � ')d O oGa -1 O a n rt 'r1 O a s r� 0=3 0 9 0 c c I 1 � i .. _ _ + �. __.. � � _ _ �_ ..�-�..4_ � _ . — — _. s - _ � 1 - _ i _ _ .. _ _ 1 . �L — i _ +�. __._ -+ . — a _ _ � _ � ---- -�--- _ j _., - __ ._ �...__ i ice, � 1 �_ _ .. _, �� . } � a I � �. I .. � _ • �� I _ _.._1� � ... — -- NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by NIGL 11 11,S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 1 OA. The debris will be disposed of in: (Location of Facility) Fire Department Sign off: Dumpster Permit -') 7�4 C Si at a of Permit Applicant Date TOWN OF NORTH ANDOVER OFFICE OF ,r BUILDING DEPARTMENT a' 400 Osgood Street North Andover, Massachusetts 01845 Gerald A. Brown Inspector of Buildings HOMEOWNER LICENSE EXEMPTION Please print DATE: f -- q -- O 1j Telephone (978) 688-9545 Fax (978)688-9542 JOB LOCATION: "I `7 JZA-�/ DV IL L F Number Street Address Map/Lot HOMEOWNER 11 JKKQ q7W —6 8 71 q 7Y— Name Home Phone Work Phone PRESENT MAILING ADDRESS Do U E P- kA'01 Lf City Town State Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other Applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE/ ltlam_` APPROVAL OF BUILDING OFFICIAL Revised 10.2005 Forth Homeowners Exemption ��