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Home My WebLink AboutDWC and Electrical - Permits - 106 ROCKY BROOK ROAD 7/6/2020 • yt��`°� s. , Commonwealth of Massachusetts Map-Block-Lot • 090.A0054 BOARD OF HEALTH ----------------------- Permit No North Andover BHP-2019-0234 ----------------------- P.I. FEE F.I. - $350.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Peter Breen - - ----------------- ------------------------ to(Construct)an Individual Sewage Disposal System. at No 106 ROCKY BROOK ROAD as shown on the application for Disposal Works Construction Permit No. BHP-2019-0 34 Dat er 31,2019 019 Issued On: Oct-31-2019 BOARD OF HEALTH ------------------ Application for Septic Disposal System TODAY'S DATE Construction Permit — TOWN OF $350.00-Full Repair NORTH ANDOVER, MA 01845 $175.00-Component Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer,use Repair or replace an existing on-site sewage disposal system* only the tab key to move your ElRepair or replace an existing system component—What? p cursor-do not RECEIVED D use the return A. Facility Information key. /O 6 Aro 04 A U 4- Address or Lott 19 TOWN OF NORTH ANDOVER CWTown HEALTH DEPARTMENT te/an 2._*TYPE OF SEPTIC SYSTEM'": ➢ X Pump ❑ Gravity(choose one) ***If pump system,attach copy of electrical permit to application' ➢ ❑Conventional System (pipe and stone system) ➢ ❑Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of yourcerfificafion to install this type ofsystem.) ➢ ❑Pressure Distribution S.A.S.(No D-Box) .➢L_1 rrES�ure uos�d'('i'i=raox-.r--.�es'en`r`)-�.A.�� ._ .... . ➢ ❑Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES=(no further info.needed) NO =(installer must specify brand of filter before DWC issuance) Whgtis the Make? Whatis the Model. 2. Owner Information Ale 4S 4L aCr Name /06 Aoc 1- Address n reritfrom aboven o�SyS Citylrown State Zip Code Email address Telephone Number 3. Installer Information A 6e r 1,3 1-ee-n Name Name of Company 770 /3c/,f-0 Sf Address /-// 4I)ao Vel- C" /To State Zip Code �.,.)'`'�, � 77o c7�/a.,�ioo. Cow 9) 8 - 6 7- -��74/ Telephone Number(Cell Phone#ifpossible pl ase� 4. Designer Information le ` Name of Company Ad s�� City/Town State n pZip Code 586 Telephone Number(Best#to Reach) Application for Disposal System Construction Permit-Page 1 of 2 Application for Septic Disposal System TODAY'SDATE Construction Permit — TOWN OF $350.00-Full Repair NORTH ANDOVER, MA 01845 $175.00-Component PAGE 2OF2 A. _Facility Information continued.... 5. TVpe of Building: MResidential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover. I understand that until a final Certificate of Compliance has been issued by this Board of Health, the installed system is not approved. Name Date Applic App d By: (Board of Health Representative) Name Date Application Disapproved for the following reasons: For Office Use OnIV: / Z FeeAttacheda Yes No 2. PtojectManaget Oblrgatron Fotnz Attache d? Yes l No 3. Pum Svstezn? Ifso Attach co ofElecttical Pew it Yes I+ No ,V J p pv AppEcantreceived copy of `Wlect acallnspectzon Notes fat Septic Systems" Yes No Handout? 4. Reviewed approvallettet,allpapetworkteceiveda Yes No Missing: S. Foundadav As Built?(new construction only): es o (Same scale as approved plan) 6. Floor Plans?(new construction only): Application for Disposal System Construction Permit.Page 2 of 2 Cf MORTM 7y 8 / / `t o s Town of North Andover HEALTH DEPARTMENT UcIN4 ! CHECK#: /On DATE:1 � LOCATION: /O 1�6 c�k- �Z A-o a�l3c� H/O NAME: CONTRACTOR NAME: Type of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing v $ ❑ Septic-Design Approval �� $ i Septic Disposal Works Construction(DWC) ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health ink-Treasurer SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: (Address of septic system) For plans by 172. (Engineer) Relative to the application of �Pi �°/ '✓�e�.✓1 �O/9 (Installer's name) And dated o 6 to Dated /o - as -a o / I?- / C/ - �Q/g o ay s ate With revisions dated (Last revised date) I understand the following obligations for management of this project: 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor,project manager, or any other person not associated with my company schedules an inspection and the system is not ready,then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or MY company a. Bottom of Bed-Generally, this is the first (V) inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection-Engineer must first do their inspection for elevations, ties, etc. As-built of verbal OK (or e-mail to: healthdept@northandoverma.gov) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system,all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade-Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer,I understand that only I may perform the work (other than simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer,I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board ofHealth staff or consultant. d. Installation of tank,D-Box,pipes, stone, vent,pump chamber,retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the gV12roved plans No instructions by the homeowner,,general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: L1 (Today's Date) �r 7ae--Print) (Name-Sign&ff Date: November 13, 2019 51351 This is an e-permit.To learn more,scan this barcode or visit northandoverma.viewpointcloud.com/#/records/55212 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that VINCENT B LANDERS has permission to perform wire sewer ejector pump wiring in the buildings of SHNEYDERMAN,ALEKSANDR, N. at 106 ROCKY BROOK ROAD , North Andover, Mass. Lic. No. 12017 *Electrical Permit Applicant Location 51351 b 106 ROCKY BROOK ROAD Vincent Landers NORTH ANDOVER, MA 01845 % 978-375-0722 Status:Complete ct7i buddy@buddyelectricinc.com Submitted:Nov 11,2019 Primary Contractor Firm(Business)Name Licensee BUDDY ELECTRIC INC VINCENT B LANDERS License# License Expiration Date 12017 07/31/2022 License Type License Active Master Electrician Class A 0 State Permit# Type of Business -- Corporation License Status Preferred Telephone#: Current 978 375-0722 Mailing Address Email , NORTH ANDOVER MA 018451807 buddy@buddyelectricinc.com Alternate Phone# I certify, under the pains and penalties of perjury,that the 9789754455 information on this application is true and complete. true Project Information TYPE OF PROJECT Is this permit in conjunction with a building permit(select yes or Fixture/Appliance New and/or Replacement(Commercial of no) Residential) No Estimated Value of Electrical Work(when required by municipal policy): 1500 Occupancy Type(NOTE: For any residential structure larger Total Number of Units than a two family please select Commercial) 1 Residential Singe Family Location and Description of Work to be Performed wire sewer ejector pump Are you installing a generator? Date Work is to Start(inspections to be requested in No accordance with MEC Rule 10,and upon completion) 11/11/2019 Panels Is This a Service Change Is This a New Service? Existing Amps(Existing Service) Proposed Amps(New Service) Existing Volts(Existing Service) Proposed Volts(New Service) Utility Authorization# Number of Feeders Location of Work Number of Ampacity Panel Change? Proposed Amps(Panel) Number of Sub Panels Temporary Service Proposed Lighting/Outlet/Circuit Work #of Recessed Luminaires #of Luminaire Outlets #of Luminaires/Exit Signs #of Receptacle Outlets #of Switches #of New Circuits undefined Total Number of Outlets/Luminaires/Switches/Circuits Proposed Appliance Work #of Ranges #of Waste Disposers #of Dishwashers #of Heater/Boiler/Furnace Wiring(Oil or Gas) #of Water Heaters #of Dryers #of Air Conditioners(room size or roof top) #of Tons #of Ceiling Suspended(Paddle Fans) #of Hydromassage Bathtubs #of Heat Pumps Electric Baseboard Heat #of Heating Appliances #of Transformers #of Washing Machines #of Microwave Ovens Repairs to wiring,outlets,and/or fixtures #of Other Appliances Not Listed Description of Appliance Not Listed undefined Total Number of Appliances Miscellaneous Fixtures #of Hot Tubs Swimming Pool Type of Pool #of Solar Panels Septic Pump Re-Wire #of Motors Motor Total HP Smoke Detectors Other type of work to be performed Fire Alarms/Security System/Data Wiring/Telecommunications Wiring Residential Fire Alarm(multi-family) Security System#of Devices or Equivalent Commercial Fire Alarm Data Wiring:#of Devices or Equivalent Telecommunication Wiring(phone cables):#of Devices or Equivalent Insurance I have a current liability insurance policy or its substantial If yes, indicate the type of coverage equivalent. If NO is selected a copy of the signed Owner's Liability Insurance Waiver form must be attached to this application. Yes If other,specify Worker's Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Are you an employer?Select the appropriate type.Any Type of project applicant that selects#1 must also fill out the section below 11. Electrical repairs or additions showing their workers'compensation policy information. 1. 1 am an employer with employees (full and/or part-time) I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name(Attach a copy of workers' Policy#or Self-Ins. License# compensation policy declaration page showing the policy 70523 number and expiration date) Utica National Expiration Date 01/22/2020 Workers' Compensation Affidavit Signature I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. true Attachments (1) pdf Worker's Compensation Insurance Affidavit Nov 11,2019 Timeline ❑ Electrical Permit Review Status:Completed November 13th 2019,7:16 am Assignee:Nabil Daher El Permit Fee Status:Paid November 13th 2019,9:24 am ❑ Permit Issuance Status: Issued November 13th 2019,9:24 am Septic Final Status:Completed November 18th 2019,7:06 am Assignee:Nabil Daher A UTICA NATIONAL INSURANCE GROUP WC 000001A y180 Genesee Street New Hartford, NY 13413 Issuing Company: Utica Mutual Insurance Company MEMBER OF UTICA NATIONAL INSURANCE GROUP WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Information Page Policy Number: 4917896 1. The Insured and Mailing Address: Prior Policy Number: BUDDY ELECTRIC, INC 24 COLGATE DR Producer: Segreve& Hall Ins Assn 1 Tech Drive, Suite 135 NORTH ANDOVER MA 01845 Andover, MA 01810 Entity of Insured: Corporation Producer Number: 70523 Other workplaces not shown above: SIC#: 1731 Insured's I.D. Number: 042966854 NCCI Company Number: 15717 Risk I.D. Number: 2. The policy period is from 01/22/2019 to 01/22/2020 12:01 AM Standard Time at the Insured's mailing address. 3. A. Workers Comppensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here:MA B. Employers Liability Insurance: Part Two of the policy applies to work In each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $1,000,000 Each Accident Bodily Injury by Disease $1,000,000 Policy Limit Bodily Injury by Disease $1,000,000 Each Employee C. Other States Insurance: Part Three of the policy applies to the states,if any, listed here: All States except those listed in Item 3A., ND,OH,WA,WY D. This policy includes these endorsements and schedules: 4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. ❑ Premium Basis Rate Per$100 See Extension of Information Page Code Estimated Annual Total est.Annual of Classifications No. Remuneration Remuneration Premium Minimum Premium: $ 285 MA Expense Constant $ Employer's Liab Minimum Premium: $ Total Estimated Annual Premium $ 3,086 If indicated below, interim adjustments of premium shall be made: Deposit Premium $ 3,086 Issuing Office: New Hartford, NY 13413 Date of Issue: 12-19-2018 Countersigned by C P�`�w 8-D-WC Ed.08-2008 Copyright 1988 National Council of Compensation Insurance BILLING NO. 200136038 OP ID:WC DATE(MMlDDNYYY) Acv�ru CERTIFICATE OF LIABILITY INSURANCE 09103/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the polic eme must a endorsed. SUBROGATION WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on thiss certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Segreve&Hall InSUr.ASSOC.Inc PHONE 978 E-MAIL -976-13DO ac No 978-976-7696 One Tech Drive,Suite 135 A/C Ext: L Andover,MA 01810 ADDRESS: — -- Lawrence J.Hall PR U E BUDDY-1 CUSTOMER ID A' INSURE S)AFFORDING COVERAGE NAIL S _ _ ---- --- 5976 INSURED Buddy Electric Inc. INSURER A:Utica NatIODa Ins.Co.o 41360 24 Colgate Drive INSURER B:Arbella Protection Ins.CO. North Andover,MA 01845 INSURERC: --- INSURER 0: -. INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFF POLICY EXP LIMITS II iR TYPE OF INSURANCE POLICY NUMBER �,MMIoo MM 1,000,00 EACH OCCURRENCE S GENERAL LIABILITY 50,00 917895 101/22/2019 01/22/2020 PREMISES Ea occurrence $- A X COMMERCIAL GENERAL LIABILITY MED FJCP(Any one person) $ 5,00 CLAIMS-MADE I A I OCCUR 1,000,QO RENTED EQUIP$10,000 PERSONAL dADVIWURV s GENERAL AGGREGATE $ 2,000,0 PRODUCTS- COMPIOP AGG S 1,000,0 00 GENL AGGREGATE uMrr APPLIES PER: I $ POLICY PRO- LOC COMBINED SINGLE LIMIT $ 1,000,00 AUTOMOBILE LLABIUTY (Ea accident) BODILY INJURY(Per person) S ANY AUTO BODILY INJURY(Per accident) S B ALL OWNED AUTOS LX S HEDULE CD AUTOS PROPERTY DAMAGE $ 1020008728 11/16/2018 11116/2019 (PER ACCIDENT) X HIRED AUTOS i $ X NON-OWNED AUTOS $ EACH OCCURRENCE S UMBRELLA LIAB OCCUR AGGREGATE S EXCESS LIAB CLAIMS-MADE I I S DEDUCTIBLE I S RETENTION S X WCYTATU TH. WORKERS COMPENSATION MIT 500,00 AND EMPLOYERS'LIABILITY i4917896 101/=019 01/22/2020 E.L.EACH ACCIDENT S A ANY PROPRIETOR/PARTNER/EXECUTIVE Y❑',,N A I E.L.DISEASE-EA EMPLOYE a 500,00 OFFICER/MEMBER EXCLUDED? I I 500,00 (Mandatory In NH) E.L.DISEASE-POUCY LIMIT $ If es,describe under DESCRIPTION OF OPERATIONS below i LES(Attach ACORD 101,Additional Remarks Schedule,it more space is required) DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHIC CANCELLATION CERTIFICATE HOLDER NORTHAN THE EXPIRATION DATE THEREOF, NOTICE ANY OF THE ABOVE DESCRIBED I WILL ES BE CBECDELVERED BEFORE Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main Street North Andover,MA 01845 AUTHORIZED REPRESENTATIVE A�1gAat-09 ACORD CORPORATION. All rights reserved. O ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD