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HomeMy WebLinkAboutMiscellaneous - 138 Middleton Street 138 MIDDLETON STREET 210/109.0-0009-0000.0 i I i I v I I Date.....4-:7.................... pAORTH O,q'I, a.'. TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING ,SSACHUS Et L) This certifies that ........... ................................................................................ has permission to perform .......... .................................... .................. wiring in the building of..........................5 - M5, at.................................................... ............ North Andover,Mass. Fee 0. ....... Lic.N ............ V!�� .............. ...... ... ;ELECTRICLL INSPECTOR 32 3 Check ft- -- 9312 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the (/\ permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted b p y an Inspector of Wires appointed pursuant to M.G.L c - . PP P . 16b,§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 rtquli'ed inMI.G.L.c.143,§3L. Permits shall-be limited as to the time of.ongoing construction activity,and may be.deemed.by thelrispector_of__Wires abandoned.and.invalid-ifhe.___. ._ or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this puipose by establishing an automatic four-year extension to certain permits and licenses concerning the 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 August 15,2 and extending through August 15,2012. ule 8—Permit/Date Closed: /2 Z ` ***Note:Reapply for new permit�Y' ❑Permit Extension Act—Permit/Date Closed: '❑ 2O1Z NPaSaarhncuH..T.l.,..aa__•n_� -. C,om.monwaaR of Mailachu�al�J Official Use Only l)aPar�man!`o1 J`iro Sarvicas Perini f No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS (Rev. 1/07] (leave blarLk) APPLI-CATION FOR P�ERNIIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC), 527 CNM 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORI11A TION) Date: 3 - .3 o-10 City or Town of: Mc� k, ll wyex- 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) 13d /0i ��1 / 9/> Owner or Tenant _ N2,e �! Qa Telephone No. -NO— Owner's Address }�'�-e.� Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Bot) Purpose of Building Utility Autborizabon No. SIIExisting Service Amps / Volts Overhead Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity j Location and Nature of Proposed Electrical Work: ` � 1 " �� C2t r w e Completion of the following table may be waived by the Inspector of 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 Swimming Pool Above In- r n. o �mergency rgnnng g arnd. Qrnd. Bat-tery Units No. of Receptacle Outlets No. of Oil Burners _ FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Detection and Initiating,Devices No. of Ranges No. of Air Cond. Total No. of Alerting Devices g Tons No. of Waste Disposers Heat Pump _Number I Tons K_ W M. of Self-Contained Totals: Detection/Alerting Devices Munici a No. of Dishwashers Space/Area Heating KW Local❑ l ti ConnecOther Heating A liances Security Systems: No. of Dryers g PP KW . No. of Devices uivalent No. of Water No. of No. of Data Wiring: KW Heaters Signs BallaBallasts s No. of Devices or Equivalent No. I:ydromaSsage Bathtubs b5 v rr'1G t0 .r- v Telecommunications Wirino- i, . ... rS T-'I- P4�T �*� - '�'E.+u;Y3�ent 0. C: De-,iczs o OTHER: 7 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: S _Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE OVERAGE: 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 M BOND ❑ OTHER F1 (Specify:) 1 certify, under the pains and penalties,ofperjury, that the information.on this application is true and complete. FIRM NAME: �� - C�u rl c-1 Ser U i tees . LIC.No.: �Z,5C Licensee: ;,�,%%/,,' q� 7411c,4' T✓ Signature LIC.NO.: /�9� -D (If applicable, enter "exempt"in the license number lin � Bus.Tel. No,:ro�� Address: 1 L-.La7 L c [)� / /[v��/s ) -23J�12 Alt. Tel. No.: *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 normally required by law. By my signature below,I hereby waive this requirement. I am the (check one) [Iowner ❑ owner's agent. t Owner/Agent . PERMIT FEE: � ��� l g Si nature � Telephone No. / i Department of P blic..Safety One Ashburton Place, Rm 1301 Boston, -Ma 0.2108-1618 License: Certificate of Clearance Number: SS CC 002577 Expires: 12/23/2i 011 Restricted To: 00 l WILLIAM M TAYLOR JR IS CLINTON DR HOLLIS, NH 03049 - Tr. no: 1420.0 Keep top for receipt and change of address notification. ,-CAI G 35M.10/09.101/6200p9LICENS EFORM I \ DEPARTMENT OF PUBLIC SAFETY Certificate of Clearance Number: SS CC 002577 r Expires: 12/23/2011 Tr. no: 1420.0 a S-License: ADT SECURITY SERVICES �• n G a r., WILLIAM M TAYLOR JR fi n Ln 18 CLINTON DR -iOLLIS, NH 03049 fo R Commissioner fo a I j , I r y N s I O m 0 C) cn r L� X p n Cn S FD 2: O ' M m z M rnCD rn LA v CD D C - \ m c I u V z O T -t u O z D LA � T - r: _ _ C_ m O 2 m D f7 � 0 0 '" Z . An I . C N C, r u to 0- L., _ n' I IU Location D/ V 7T No. 4Date 16,y r/ Of TOWN OF NORTH ANDOVER NORTH .6 3? ^� 0 .- o p Certificate of Occupancy $ 5�-- g_ � I ° * Building/Frame Permit Fee $ �+s °'�t� Foundation Permit Fee $ — l G v JAcMusE �,. Other Permit Fee $ ------ Sewer `Sewer Connection Fee $ N�� /QG )�aW Leer Connection Fee $ N /©D '/p 4 ,,99 TOTAL $ 6-;-'.T0✓O/. oozy. Building Inspector Div. Public Works Location i ` i�1y� !�� '7��_, 1c�, o) No. %' Date tad. /;S/ Of NORTH TOWN OF NORTH ANDOVER Certificate of Occupancy $ + ; x Building/Frame Permit Fee $ CM�g<� Foundation Permit Fee $ Other Permit Fee $ 4 `ewer Connection Fee $ M p Water Connection Fee $ fMD ,� TOTAL CAP cBuilding Inspector" i 00V Q �. Div. Public Works s \ PERJIIT NO.� 5�. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. / f7 " PAGE 1 I r MAP d40. I® d LOT NO. f7C2 RECORD OF OWNERSHIP iDATE BOOK 'PAGE 10NE t?-/1 7 I SUB DIV. LOT NO. .., I a� / I-OA 3o I ��0 LOCATION uC 3 0 `'D l � PURPOSE OF BUILDING '�,e �,I� OQ /l OWNER'S NA £"3 J �J ;N-� (`u.� ry NO. OF STORIES SIZE OWNER'S A -RESS V \! BASEMENT OR SLAB U�r( G, ARCHITECTS NAME Z!/� SIZE OF FLOOR TIMBERS IST J u �e72NND '1/ 3RD r BUILDER-99,J-NAME RO �` �+ SPAN DISTANC 'f0 NEAREST BUILDING •J DIMENSIONS OF SILLS i1;•1�!) t ' 1� DISTANII, FROM STREET �® POSTS DISTAN FROM LOT LINES-SIDES REAR i'f ��"" " " GIRDERS AREA LOT ®Q C)Oo J j. FRONTAGE O� Fr HEIGHT OF FOUNDATION 7 )/ THICKNESS i r/ V IS BUIL ING NEW t SIZE OF FOOTING �h 11 X IS BUILDING ADDITION A 0 MATERIAL OF CHIMNEY � v IS BUILDING ALTERATION 0 IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE y es IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY NOME IS BUILDING CONNECTED TO TOWN SEWER Al o �V IS BUILDING CONNECTED TO NATURAL GAS LINE /1/ INSTRUCTIONS 3 PROPERTY INFORMATION ono , tw SEE BOTH SIDES �`EfiMIY FOR FOUNDATION ONLY LAND COST O� EST. BLDG. COST �� AMWED 8Y PARA-112.7 S.8.C. PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT.ello, zoo PAGE 2 FILL OUT SECTIONS 1 - 12 f-/FEE PAID: EST. BLDG. COST PER ROOM /s-d o,oo SEPTIC PERMIT NO. J/9O ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY t ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR t / .�{ DATE FILED lo - 17- 11 C='`�� ��� -� /v/'J° 6, BOARD OF HEALTH SIGNATU F OWNE R AUTHORIZED AGENT F E'E = CONTR.TEL.#.....,.....,,.,�,,,�,,. CONTR.LIC.# PLANNING BOARD PERMIT GRANTED OC.T'T 17 19 q/ o j o BLDG. PERW fEE$ S7 PERMIT FOR FRAME/BUILDING ass FDA FEE. ,- oo BOARD OF SELECTMEN DATE: FEE PAID ' :.� :f` FRAME PERMIT Ta T-A-t Dice g-� BUILDING INSPECTOR BUILDING RECORD 1 OCCUPANCY 12 , SINGLE FAMILY STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS`OF••-BUIL"DINGS. WITH PORCHES. GA- APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH f �^ CONCRETEI _ dI9— [ J CONCRETE BIL K. PINE BRICK OR STONE HARDW D PIERS PLASTER _ DRY WALL _ UNFIN. ....................,....-.. 3 BASEMENT AREAULL FIN. B'M'TAREA _ y, T '/' FIN. ATTIC AREA _ NO BMT FIRE PLACES HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROPFSIDING CONCRETE WOO SHINGLES EARTH _ j ASPHALT SIDING HARDW D ASBESTOS SIDING _ COMIr1CN VERT. SIDING ASPH.TILE STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. 8 BRICK ON FRAME CONC. OR CINDER BLK. '9 „� :A STONE ON MASONRY — WIRING �S R STONE ON FRAME �lY SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE HIP BATH (3 FIX.) I GAMBREL MANSARD TOILET RM. (2 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING /(p WOOD JOIST PIPELESS FURNACE _ FORCED HOT AIR FURN. V ]" TIMBER BMS. &COLS. STEAM E^/,V /N9 STEEL BMS. & COLS. HOT W'T'R OR VAPOR n WOOD RAFTERS X AIR CONDITIONING �ll�IJ. Gl°I2/,I�f RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GASr OIL 075 B'M'T C) 2nd _ ELECTRIC 1st 7 13rd I NO HEATING � r 6Q.o,uoiAT���so Lal- � OF .PSG O.e G� r�.f �B'i2 L oT�Q,2E I 9 I �I "J o.• ' o i I EXrsT. Gh F 6a R. o oJdca � c BUILDING DEPARTMENT S //EREBY CE.cT/FY TO TyE' T/TLE/,t/SU.PO.t'qt/O RL O T TO Tf/E B.4 N,Y T.s�gT T//E OwELL./.ti6/,S f01CATE0 ON TyE LOT�4S S/.f�/Y.t/ANO T//�4T/T OGEES CO.t/iGZPA! /N !Y/T/! TiS/Etow✓✓ OFA A&Do✓vc ZON/N6 CE6!/LATi!'J.(rS , 6�4.Q0/.t/G SETBACit'S FEDI!ST.PEETS w,- S FU.�TyE.P GE.PT/FY T.y4T 7WI-f OM'ELL/AV6 /s VOT GOLATEO /� TyE;FEOE�PAL..,f,COioO H.9ZA.P0 A.PEA. O�PAir/V FO.P SyawN OA-0 AWAY 4elo//T P --4 0500,78 oV/SB BEST c �GE/i 6TTE- 0 r •�\ �TEG.JaNE/S / 'e S/Yl/17.T .�,�,,off," w aPvcPOSES-tiOT FO.P �E��/�A���6/•t/EE.P/�(/6 SE.P/�/CES BOUNO.PS��IE'T��Olfi�/f1T/Or(� BDU.VpA.PY ,47-10-v 7Wee-V ,�,Po,H ExrsT�.vc .eEc�o,Pvs. 6G ��4�P.E� xrllnEET A.VODI�E.�, /yJ.4SS.4G,Y//SETTS o/8�0 FORM U TOWN OF NORTH ANDOVER s LOT RELEASE FORM i SUBDIVISION ASSESSORS MAP S BB+V 6478N-LOT(S) PERMANENT ADDRESS SSIGNED BY D.P.W. STREET APPLICANT,y2U,,, p-j��. PHONE b7_ -�/0 O DATE OF APPLICATION ,���,� /q/ TOWN USE BELOW THIS LINE PLANNING OARD l `r DATE APPROVED �� • � • TOW PLANNER DATE REJECTED CONSERVATION COM MISSION UTE APPROVED CONSERVA ON ADMIN. ATE REJECTED BOARD OF HE LT DATE APPROVEDJ'/27 �f iS r 'AL'i'll NITARIAN DATE REJECTED 71L DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERMIT SEWER/WATER CONNECTIONS aX FIRE DEPT. <. RECEIVED BY BUILDING INSPECTION DATE o -- ly—j This form shall be signed by the agents of the Planning and Health Boards, the Conservation Commission prior to the issuance of any building permits for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. �-��- �9G ., • r ` Town of North Andover BUILDING DEPARTMENT Homeowner License Exemption (Please print) DATE JOB LOCATION �3 �`��� TDN ;9, FYker Fwcr7 Number Street Address Section of Lown HOMEOWNER"_ 1�.��,erT J i�,M So�� ���-�►�8a Name Home Phone Work Phone I ' ' PRESENT MAILING ADDRESS City Town State Zip code The current exemption for "homeowners" was extended to include owner -occupied dwellings of six units or less and to allow such homeowners to . engage an individual for hire who does not possess a license , provided ethat the owner acts as supervisor. (State Building Code, Section 109 . 1 . 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 to six family dwell- ing , attached or detached structures accessory to such use and/or farm structures . A person who constructs more than one home in a two-year period shall not be considered a homeowner . Such "homeowner" shall submit to the Building Official , on a form acceptable to the Bulding Official , that he/she shall be responsible for all such work performed under the `building permit . (Section 109 . 1 . 1) The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other applicable codes , by-laws , rules and 'regulations . The undersigned "homeowner" certifies that he/she undersea►ids the Town of North Andover Building Department minimum inspection procedures and 'requirements and that he/she will comply with said procedures and ` ,requirements . -HOMEOWNER ' S SIGNATURE . APPROVAL OF BUILDING OFFICIAL 'Note : Three family dwellings 35 , 000 cubic feet , or larger , will be required to comply with State Building Code Section 127 . 0 , Construction Control . ��1���7��� 'wn o ` 6 O ndover L O ' �VEVVAY ENTRY PEP er, Mass. 7 1971 SMT _ > > r :•' x BOARD OF HEALTH t41 h f THIS CERTIFIES THAT...W � ..... �../.l. ................ BUILDING INSPECTOR has permission to erect ....."moo" )� buildings on ....�. � Rough . � �•. ............ Chimney 11ho to be occupied as.......... ... .. Xtconform ....� �. '!................. Final provided that the person accepting this permit shall in every respe to the terms of the application on file in PLUMBING INSPECTOR this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of- Rough Buildings in the Town of North Andover. PERMIT FOR FOUNDATION ONLY Final - REGULATED B PARA: 112.7 S.B.C. VIOLATION of the Zoning or Building Regulations Voids this Permit. REGULATED PAID: _ PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR Rough UNLESS_ CONSTRU Service Final ....... ..... ....... .. PERMIT FOR FRAME/BUILDING ....... ....... BUILDING INSPECTOR GAS INSPECTOR DATE- —7— ermit Required to Occupy Building Rough p�Od Final Display in plcuous Place on the Premises Do Not Remove Burner FIRE DEPT. No Lathing P pp 1 to Be Done Until Inspected and Approved by STREETR: . Smoke Det. Building Inspector - - OF r10RTI�1 9 sSgCHUg� TOWN OF NORTH ANDOVER MASSACHUSETTS BOARD OF APPEALS Ili TO: JAMES GORDON, TOWN MANAGER FROM: L. DUFRESNE, ZONING BOARD OF APPEALS DATE: OCTOBER 3, 1991 RE: ROBERT & FLEURETTE SIMS PROPERTY AT 9 MIDDLETON ST. Please note the. attached letter from the Harold Parker State Forest Advisory Committee concerning the above party who plans to build a home on the listed address. The Simms' are scheduled to come before the Board on October 8, 1991 request- ing a variance in order to build a home on land located in Harold Parker State Forest. cc: )Robert Nicetta, Building Inspector Karen Nelson, Dir. Planning & Development Buddy Cyr, DPW it �? OCT - 4 f To: North i M iu o'vel" E�G.�t'u o'1 Appeal S Fr o,m- Harold Stllte Forest Ad'ViJot u Committee Re: Petition far •, a, -,inces bu Robert .and Flourette Simms to permit con,-tr-uction of a d,Ielling at 9 Middleton Rd. in North Andover Mi i Ls meeti,-iq oiri Sept. i IS, i 91 , the Harold Parker ;tate Forest !iu';'I `or"U C-0- it_n i ttee di--us;-,ed the above petition and 'voted unanimous)g to subt-nit to your Boord thO folloivinq staterrient for the record T tie I-laro?d 1'ur1:Gr Jlate Forest advisor-q Cori mittee does not object to the: grant of the %jar-i,-aces requested provided that the Town of Northndo°ve-r i is prepared to pr"ovide road maintenance and plo�;virig, fire and police protection., _chool bus service, and trach collection to ser,lie the ne%, d*'elling. These are To,,'•,'n responsibilities and the Committee feel~ "..'ery :ltromgl!a that the Departrnent of Environmental Management (DEM should not be e:>;pect ed to pro%-�i de any of them. If this petition i s granted, it should be clearly understood that the To-vvn accepts these responsibilities and that present .grid future can feel secure that thea •,-gill recei':e all usual Tovvn ser';ices. - The Committee appreciates this opportunity to present our for !4'Ju; consideration and hopes, that they will be helpful to your deliberations. Haro)d Pari%er State Forls.t Advisory Committee ter i d o,Y,e r" I.:1as,- Cf 1 r1 1 f`I cc: i:avid na I. Super `;'iSor, rcgiori DEI I Clruce Colburn, E:uper'Ytisor, Harold Parker State Forest Nichol-,s 1`;. `:'ont cIides, Legal Counsel, DEH Location j i f Y I 1 D DL E= 70A) A � No. C `/ S - Date �/� �A Z NORTH TOWN OF NORTH ANDOVER Certificate of Occupancy $ ` • ; Building/Frame Permit Fee $ • e� .«ter.:.. ,.�+ Foundation Permit Fee $ SACHUS Quer Permit Fee $ ®wo%fewer Connection Fee $ \�� Water Connection Fee $ TOTAL /II $ — -:5 Efuhding fn ecl& 5 ! Div. Public Works Location No. Date NORT" TOWN OF NORTH ANDOVER Certificate of Occupancy $ • ; Building/Frame Permit Fee $ cMusE C <� Foundation Permit Fee $ s+ 0M aer Permit Fee $ p� Sewer Connection Fee $ Mater Connection Fee $ pQ� TO $ Building Inspector Div. Public Works NUIV11I ��N1)0VE. lt h;�nlls , ;ii )Ntil it(Vi\'17ON \ I►I 1NIt IN 1W It;1 ;I's;tii;.•t ; ANN1N(P. PLANNIN(; & 'COtllAWNITY U1:N'l:LO1'I111:N'1' r KA t1-.1d 11.1 Nl:l.til )N. 1 )Il(1:(:,l OI I. C11I�INEY All LI(.AIIOId ANO. 1LI,Mff -E 1'EIZ1Il'1'. AT ION_ X -2 0 / //�?G��iy> �� ��,,•�L _-R'S NAME: I _VER'S NAME: �y N's NAME: N'S ADDRESS: / &IR&Y 8.1//l/ ST A16,6,)6 TDA/ 'N'S TELEPHONE: c 72 � /7� RIAL OF CHIMNEY: ,q a :– RIOR CHIMNEY: — L'XILRIOR CHIMNEY: ER AND­SIZE OF FLUES: -- 'KNESS OF HEARTH: ' cUbilley on. 6iAep•Cace cojiOm l to 41te. Acqu,immen t:3 u( the cute and have ,tutn and ATURE OF MASON: IT GRANTED: FEE � 6- C9-0 T NICETTA DING INSPEC7 =CTEV: K,S: SOLID BLOCK RE ullum g THIS PERMIT MIIS F BE U I.SPLAYL V 014 711E I'RLAU SL S RECEIVED 'C"N Commonwealth of Massachusetts NOV - 9 2005 City/Town of NO. ANDOVER System Pumping Record TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Form 4 �M 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. A. Facility Information Important: When filling out 1. System Location: forms on the computer,use 138 MIDDLETON ST. only the tab key Address to move your NO. ANDOVER MA 01845 cursor-do not City/Town State Zip Code use the return key. 2. System Owner: t� ROBERT SIMMS Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 10/15/05 2. Quantity Pumped: 000 Date Gallons 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: 6. System Pumped By: Benjamin Shute H79 406 Name Vehicle License Number J's Septic& Drain Company 7. Location where contents were disposed: GLSD a 10/15/05 5 re Hauler V Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 t , . I r � GQA✓o F.eTNd.2SC �aT � �F OF �1TG O.E G� /�S PeiQ LOT�,eCr,� •; =•39,250-s.f Oma' i(/D.ert/ �.voorC� I; N IL ?I � p � 1T. lv�F 6HR. 1 r�/.aOGE7 aV JTGEL�T • E BUILDING DEPARTMENT •1 //EREBY CE.cT/FY To r.YE r�rl�/,vsa.�O.C.avo Rz. or TO THE B.4.VE T.ygT THE O/✓ELG/.WC/S GO ,4TEO ON IN Tf/E GOT.!S S�/�'•t/ANO Ti4G4T?OOSS GGtt/FGtiPA/ 1Y/Tip/ T.S�E r"o�� O/�'�A�oOvte ZON/•t�6 .CE6!/LAT.I�t�S � � �QL�6wI.e0/.W SETQAC.t'S F•e0A/ST.PEG?S r GOT L/•tiES.' /C/O.er.�/ �.v00✓6i2//�iPS�" r FarT.s�cr GE,�T/,rY T•V.IT TiY/S GSM'E!1/iY6 /Sit/OT O.PAi1�iV IOW ' LOG4TE0 /� TyE:,FG"AE.�,iOG.f+C�O //.4Z.�1E0 AREA. ,. AWre 64 A/E,P,P//ygGt'�-,�/6•u/EE.P/.1/6 SE.Pr/lES Bovvo.Py �'��+Y��.grioi! .�oavo•ver/,�/FoR.s1- .ST.rEET A,t/ODi'E�, y�,gs,�gCyl/SE7TS o/8/O