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HomeMy WebLinkAbout- Permits - 1 PENNI LANE 3/21/2019 i - - __ Map-Block-Lot Commonwealth of Massachusetts //% • 107.D0057 ----------------------- BOARD OF HEALTH Permit No North Andover BHP-2019-0048 FEE ------------- DISPOSAL, WORDS CONSTRUCTION PERMIT Permission is hereby granted Dean Dynan to(Construct)an Individual Sewage Disposal System. at No 1 PI MINI LANE "'. �° ,. 'i as shown on the application for Disposal Works Construction Permit No. BHP- 019 048 D 21 2()19 Issued On: Mar-21-201.9 BOA-D OF Hl'A TH i I 1 I 1"£AWN OF NORTtt ANDOVER Permit Number N(.'lRT[I ANDOVE'R, MASSAC11l.JSETTS 01845 ORYM Date Issued. 0 <4•u .4 sa�� ��Y4�a71 expiration Date TO (w Jack- c' Law -- Permit Application. Pursuant to G.L. c» 82A §1 and 520 CMR 7.00 et seq.(as amended) THIS PEItM I'MUS`r BE FULLY COMPLETED PRIOR TO (UONSIDERA,TION Name of Applicant : ( ���Gt� tPhone Cell Street Address r Cityll"own MA ZIP Name of Excavator(if different from applicant) Phone Cell Street Address Name of Owner(s)of Prtrpertr Phone Cell v/ � Street Address Cityffown MA ZIP % fI V1 Other Contact Permit Fee Received No Yes�__4__._, Description,location and purpose of proposed trench: Please describe the exact location of the proposed trench and its purpose(include a description of what is(or is Intended)to be laid In proposed trench(eg; pipeslcable lines etc,.)Please use reverse side it additional space is needed, ✓',r✓p�%4..- -"�1..�/J 1�.'/�'�"1 � 'f+i/`�"` �..y C-6^"� �G.� � ''.. /�L�"�'�G^'� �,C //�`"� r, ,,� �""'�"�/�� Insurance Certificate#: ~� Name and Contact Information of Insurer: Dig Safe Mime of Competent Person(as defined by 520 CMR 7,02): Massachusetts'lloisting License# License Grade: Datc- .......... ................. BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT THEY ARE FAMILIAR WITH, OR, BEFORE COMMENCEMENT OF THE WORK, WILL BECOME FAMILIAR WITH, ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED, INCLUDING OSHA REGULATIONS, G.L. c. 82A,520 CM11 7.00 et seq., AND ANY APPLICABLE ',MUNICIPAL ORDINANCES, BY-LAWS AND REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMFI' ISSUED FOR SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WrJ'H THE CONDITIONS:SET FORTH BELOW. THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE EXCAVATOR TO UNDERTAKE, SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO, FOR TIJE DURATION OF(,'ONs-rRtl("FION, ,8,UT14ORIZES PERSONS DULY APPOINTED BY TnE MUNICIPALITY TO ENTER UPON THE PROPEWI'Y TO MONITOR AND INSPECT TIIE WORK FOR CONFORMITY WITH THE CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS GOVERING SUCH WORK. THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO REIMBURSE THE MUNICIPALITY FOR ANY AND AL,L COSTS AND EXPENSE S41'r`QJRRED BY THE MUNICIPALITY IN CONNECTION WITH,THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURES TAKEN BY THE MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED NECESSARY BY THE MUNICIPALITY. THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,INDEMNIFY, AND HOLD HARMLESS THE MUNICIPALITY AND ALI,OF ITS AGENTS AND EMPLOYEES FROM ANY AND ALL LIABILITY, CAUSES OR ACTION,COSTS,AND EXPENSES RESULTING FROM OR ARISING OUT OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT. rW DATE EXCAVATOR SIGNATURE (IF DIFFERENT) DATE OWNERIS SIGNATURE(IF DIFFERENT) DATE: 2 P agr. ra H v r � a � Fown of North Andover t " '•4:, ';:. �' HEALTH DEPA .fME ' �SIACNU9eA t f CHECK#. DATE: LOCATION e H/O NAME:CONTRACTOR NAME: Tyne of Permit or 13�: (Check box) ® Animal • Body Art Establishment -- ❑ Body Art Practitioner • Dumpster � 0 Food Service- 0 Funeral Directors $ — — • Massage Establishment — ® Massage Practice • Offal(Septic)Hauler � ® Recreational Camp $ ® Sun tanning • Swimming Pool � ® Tobacco 0 Trash/Solid Waste Hauler -- © Well Construction SEPTIC Systems: 13 Septic-Soil Testing 0 Septic-Design Approval � i © Septic Disposal Works Construction(DWC) 0 Septic Disposal Works Installers(DWI) $ © Title 5 Inspector -- — * Title 5 Report � Other:(Indicate).-�.- ealth Agent Initials i White-Applicant ja y-Health I?isak-Treasurer _ ti �