HomeMy WebLinkAboutMiscellaneous - 549 Osgood Street 549 OSOOOD STREETj��
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107 FOREST STREET FILE# 110201A
MIDDLETON,MA 01949
(978)774-7122
ENVIRONMENTAL
SOLUTIONS, CORP.URRIER
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PROPERTY OWNER'S NAME: MARY F. CHARLES TRUST.
PROPERTY ADDRESS: 549 OSGOOD ST. N.ANDOVER,MA
ADDRESS OF OWNER: SAME -
(IF DIFFERENT) DEC
2001
x � 1
DATE OF INSPECTION: NOVEMBER 2, 2001
i
NAME OF INSPECTOR: THOMAS J. CHIGAS
* THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY
107 FOREST STREET FILE# 110201A
MIDDLETON,MA 01949
(978)774-7122
ENVIRONMENTAL
SOLUTIONS, CORP.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
PROPERTY ADDRESS:549 OSGOOD ST. NAME OF OWNER: MARY F. CHARLES TRUST
N. ANDOVER,MA ADDRESS OF OWNER: SAME
DATE OF INSPECTION:NOVEMBER 2,2001
NAME OF INSPECTOR: (PLEASE PRINT)THOMAS CHIGAS
COMPANY NAME: CURRIER ENVIRONMENTAL SOLUTIONS CORP
MAILING ADDRESS: 107 FOREST STREET• MIDDLETON, MA 01949
TELEPHONE NUMBER: (978) 774-7122
CERTIFICATION STATEMENT
I CERTIFY THAT I HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION
REPORTED BELOW IS TRUE,ACCURATE,AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PREFORMED BASED ON MY
TRAINING AND EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON-SITE SEWAGE DISPOSAL SYSTEM.I AM A DEP SYSTEM
APPROVED INSPECTOR PURSUANT TO SECTION 15.340 OF TITLE 5(310 CMR 15.000).THE SYSTEM:
PASSES
YES CONDITIONALLY PASSES
NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY
FAILS
INSPECTOR'S SIGNATURE: r DATE: NOVEMBER 2,2001
THE SYSTEM INSPECTOR SHALL SUBMIT A COPY OF THIS INSPECTION REPORT TO THE APPROVING AUTHORITY(BOARD OF HEALTH OR DEP)
WITHIN 30 DAYS OF COMPLETING THIS INSPECTION. IF THE SYSTEM IS A SHARED SYSTEM OR HAS A DESIGN FLOW OF 10,000 GPD OR
GREATER,THE INSPECTOR AND THE SYSTEM OWNER SHALL SUBMIT THE REPORT TO THE APPROPRIATE REGIONAL OFFICE OF THE DEP.
THE ORIGINAL SHOULD BE SENT TO THE SYSTEM OWNER AND COPIES SENT TO THE BUYER,IF APPLICABLE,AND THE APPROVING.
NOTES AND COMMENTS:
N/A
****THIS REPORT ONLY DESCRIBES CONDITIONS AT THE TIME OF INSPECTION AND UNDER THE CONDITIONS OF
USE AT THAT TIME. THIS INSPECTION DOES NOT ADDRESS HOW THE SYSTEM WILL PERFORM IN THE FUTURE
UNDER THE SAME OR DIFFERENT CONDITIONS OF USE.
REVISED 6/15/2000 PAGE 1 OF 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
PROPERTY ADDRESS:549 OSGOOD ST.
OWNER:MARY F.CHARLES
DATE OF INSPECTION:NOV 2.2001
INSPECTION SUMMARY: CHECK A,(B C,D OR E/ALWAYS COMPLETE ALL OF SECTION D
A. SYSTEM PASSES:
NO I HAVE NOT FOUND ANY INFORMATION,WHICH INDICATES THAT ANY OF THE FAILURE CRITERIA
DESCRIBED IN 310 CMR 15.303 OR 310 CMR 15.304 EXIST. ANY FAILURE CRITERIA NOT EVALUATED ARE
INDICATED BELOW.
COMMENTS:
i
B. SYSTEM CONDITIONALLY PASSES:
YES ONE OR MORE SYSTEM COMPONENTS AS DESCRIBED IN THE"CONDITIONAL PASS"SECTION NEED TO BE
REPLACED OR REPAIRED. THE SYSTEM,UPON COMPLETION OF THE REPLACEMENT OR REPAIR,AS APPROVED
BY THE BOARD OF HEALTH,WILL PASS.
ANSWER YES,NO,OR NOT DETERMINED(Y,N,OR ND)IN THE FOR THE FOLLOWING STATEMENTS. IF"NOT
DETERMINED,"PLEASE EXPLAIN.
NO THE SEPTIC TANK IS METAL AND OVER 20 YEARS OLD OR THE SEPTIC TANK(WEATHER
METAL OR NOT)IS STRUCTURALLY UNSOUND,EXHIBITS SUBSTANTIAL INFILTRATION OR
EXFILTRATION,OR TANK FAILURE IS IMMINENT. SYSTEM WILL PASS INSPECTION IF THE
EXISTING TANK IS REPLACED WITH A COMPLYING SEPTIC TANK AS APPROVED BY THE BOARD
OF HEALTH. A METAL SEPTIC TANK WILL PAS INSPECTION IF IT IS STRUCTURALLY SOUND,NOT
LEAKING AND IF A CERTIFICATE OF COMPLIANCE INDICATING THAT THE TANK IS LESS THAN 20
YEARS OLD IS AVAILABLE.
ND EXPLAIN:
YES OBSERVATION SEWAGE BACKUP OR BREAKOUT OR HIGH STATIC WATER LEVEL IN THE
DISTRIBUTION BOX IS DUE TO BROKEN OR OBSTRUCTED PIPE(S)OR DUE TO A BROKEN,SETTLED
OR UNEVEN DISTRIBUTION BOX. SYSTEM WILL PASS INSPECTION IF(WITH APPROVAL OF THE
BOARD OF HEALTH).
NO BROKEN PIPE(S)ARE REPLACED
NO OBSTRUCTION IS REMOVED
YES DISTRIBUTION BOX IS LEVELED OR REPLACED
ND EXPLAIN:
NO THE SYSTEM REQUIRED PUMPING MORE THAN FOUR TIMES A YEAR DUE TO BROKEN OR
OBSTRUCTED PIPE(S). THE SYSTEM WILL PASS INSPECTION IF(WITH APPROVAL OF THE BOARD
OF HEALTH):
NO BROKEN PIPE(S)ARE REPLACED
NO OBSTRUCTION IS REMOVED
REVISED 6/15/2000 PAGE 2 OF 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
PROPERTY ADDRESS:549 OSGOOD ST.
OWNER:MARY F.CHARLES
DATE OF INSPECTION:NOV 12001
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
NO CONDITIONS EXIST WHICH REQUIRE FURTHER EVALUATION BY THE BOARD OF HEALTH IN ORDER TO
DETERMINE IF THE SYSTEM IS FAILING TO PROTECT THE PUBLIC HEALTH, SAFETY,AND THE ENVIRONMENT.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE
WITH 310 CMR 15.303 (1)(B) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
N/A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF SURFACE WATER
N/A CESSPOOL OR PRIVY IS WITHIN
50 FEET OF A BORDERING VEGETATED WETLAND
OR A SALT MARSH.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,
IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT
PROTECTS THE PUBLIC HEALTH,SAFETY AND ENVIRONMENT:
NO THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM(SAS)AND THE
SAS IS WITHIN 100 FEET OF A SURFACE WATER SUPPLY OR TRIBUTARY TO A SURFACE
WATER SUPPLY.
NO THE SYSTEM HAS A SEPTIC TANK AND SAS AND THE SAS IS WITHIN A ZONE I OF
PUBLIC WATER SUPPLY.
NO THE SYSTEM HAS A SEPTIC TANK AND SAS AND THE SAS IS WITHIN 50 FEET OF A
PRIVATE WATER SUPPLY WELL.
NO THE SYSTEM HAS A SEPTIC TANK AND SAS AND THE SAS IS LESS THAN 100 FEET
BUT 50 FEET MORE FROM A PRIVATE WATER SUPPLY WELL.METHOD USED TO
DETERMINED DISTANCE
THIS SYSTEM PASSES IF THE WELL WATER ANALYSIS, PERFORMED AT THE DEP
CERTIFIED LABORATORY,FOR COLIFORM BACTERIA AND VOLATILE ORGANIC
COMPOUNDS INDICATES THAT THE WELL IS FREE FROM POLLUTION FROM THAT
FACILITY AND THE PRESENCE OF AMMONIA NITROGEN AND NITRATE NITROGEN IS
EQUAL TO OR LESS THAN 5 PPM,PROVIDED THAT NO OTHER FAILURE CRITERIA ARE
TRIGGERED. A COPY OF THE ANALYSIS MUST BE ATTACHED TO THIS FORM.
3 OTHER:
N/A
REVISED 6/15/2000 PAGE 3 OF 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
PROPERTY ADDRESS:549 OSGOOD ST.
OWNER:MARY F.CHARLES
DATE OF INSPECTION:NOV 2.2001
D. SYSTEM FAILURE CRITERIA APPLICABLE TO ALL SYSTEMS:
YOU MUST INDICATE"YES"OR"NO"TO EACH OF THE FOLLOWING FOR ALL INSPECTIONS:
YES NO
NO BACKUP OF SEWAGE INTO FACILITY OR SYSTEM COMPONENT DUE TO AN OVERLOADED OR CLOGGED SAS
OR CESSPOOL.
NO DISCHARGE OR PONDING OF EFFLUENT TO THE SURFACE OF THE GROUND OR SURFACE WATERS DUE TO
AN OVERLOADED OR CLOGGED SAS OR CESSPOOL.
NO STATIC LIQUID LEVEL IN THE DISTRIBUTION BOX ABOVE OUTLET INVERT DUE TO AN OVERLOADED OR
CLOGGED SAS OR CESSPOOL.
N/A LIQUID DEPTH IN CESSPOOL IS LESS THAN 6'BELOW INVERT OR AVAILABLE VOLUME IS LESS THAN'/:DAY
FLOW.
NO REQUIRED PUMPING MORE THAN 4 TIMES IN THE LAST YEAR NOT DUE TO CLOGGED OR OBSTRUCTED PIPE
(S). NUMBER OF TIMES PUMPED
NO ANY PORTION OF THE SAS,CESSPOOL OR PRIVY IS BELOW THE HIGH GROUND WATER ELEVATION.
N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 100 FEET OF A SURFACE WATER SUPPLY OR TRIBUTARY
TO A SURFACE WATER SUPPLY.
N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN A ZONE I OF A PUBLIC WELL.
N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF A PRIVATE WATER SUPPLY WELL.
N/A ANY PORTION OF A CESSPOOL OR PRIVY IS LESS THAN 100 FEET BUT GREATER THAN 50 FEET FROM A
PRIVATE WATER SUPPLY WELL WITH NO ACCEPTABLE WATER QUALITY ANALYSIS. [THIS SYSTEM PASSES IF THE
WELL WATER ANALYSIS,PERFORMED AT A DEP CERTIFIED LABORATORY,FOR COLIFORM BACTERIA AND
VOLATILE ORGANIC COMPOUNDS INDICATES THAT THE WELL IS FREE FROM POLLUTION FROM THAT
FACILITY AND THE PRESENCE OF AMMONIA NITROGEN AND NITRATE NITROGEN IS EQUAL TO OR LESS THAT 5
PPM,PROVIDED THAT NO OTHER FAILURE CRITERIA ARE TRIGGERED. A COPY OF THE ANALYSIS MIST BE
ATTACHED TO THIS FORM.]
NO (YES/NO)THE SYSTEM FAILS. I HAVE DETERMINED THAT ONE OR MORE OF THE ABOVE FAILURE CRITERIA EXIST
AS DESCRIBED IN 310 CMR 15.303,THEREFORE THE SYSTEM FAILS. THE SYSTEM OWNER SHOULD CONTACT THE
BOARD OF HEALTH TO DETERMINE WHAT WILL BE NECESSARY TO CORRECT THE FAILURE.
E. LARGE SYSTEMS:
i
TO BE CONSIDERED A LARGE SYSTEM THE SYSTEM MUST SERVE A FACILITY WITH A DESIGN FLOW OF 10,000 GPD TO
15,000 GPD.
YOU MUST INDICATES EITHER"YES"OR"NO"TO EACH OF THE FOLLOWING:
(THE FOLLOWING CRITERIA APPLY TO LARGE SYSTEMS IN ADDITION TO THE CRITERIA ABOVE)
NO THE SYSTEM SERVES A FACILITY WITH A DESIGN FLOW OF 10,000 GPD OR GREATER(LARGE SYSTEM)AND THE
SYSTEM IS A SIGNIFICANT THREAT TO PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT BECAUSE ONE OR MORE OF
THE FOLLOWING CONDITIONS EXIST:
YES NO
NO THE SYSTEM IS WITHIN 400 FEET OF A SURFACE DRINKING WATER SUPPLY
NO THE SYSTEM IS WITHIN 200 FEET OF A TRIBUTARY TO A SURFACE DRINKING WATER SUPPLY
NO THE SYSTEM IS LOCATED IN A NITROGEN SENSITIVE AREA(INTERIM WELLHEAD PROTECTION AREA-IWPA)
OR A MAPPED ZONE II OF A PUBLIC WATER SUPPLY WELL
IF YOU HAVE ANSWERED"YES"TO ANY QUESTION IN SECTION E THE SYSTEM IS CONSIDERED A SIGNIFICANT THREAT, OR
ANSWERED "YES" IN SECTION D ABOVE THE LARGE SYSTEM HAS FAILED. THE OWNER OR OPERATOR OF ANY LARGE
SYSTEM CONSIDERED A SIGNIFICANT THREAT UNDER SECTION E OR FAILED UNDER SECTION D SHALL UPGRADE THE
SYSTEM IN ACCORDANCE WITH 310 CMR 15.304. THE SYSTEM OWNER SHOULD CONTACT THE APPROPRIATE REGIONAL
OFFICE OF THE DEPARTMENT.
REVISED 6/15/00 PAGE 4 OF 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
PROPERTY ADDRESS:549 OSGOOD ST.
OWNER:MARY F.CHARLES
DATE OF INSPECTION:NOV 2.2001
CHECK IF THE FOLLOWING HAVE BEEN DONE. YOU MUST INDICATE"YES"OR"NO"AS TO EACH OF
THE FOLLOWING:
YES NO
YES PUMPING INFORMATION WAS PROVIDED BY THE OWNER, OCCUPANT, OR BOARD OF
HEALTH.
NO WERE ANY OF THE SYSTEM COMPONENTS PUMPED OUT IN THE PREVIOUS TWO WEEKS?
i
YES HAS THE SYSTEM RECEIVED NORMAL FLOWS IN THE PREVIOUS TWO-WEEK PERIOD?
NO HAVE LARGE VOLUMES OF WATER BEEN INTRODUCED TO THE SYSTEM RECENTLY OR
AS PART OF THIS INSPECTION?
N/A WERE AS BUILT PLANS OF THE SYSTEM OBTAINED AND EXAMINED? (IF THEY WERE NOT
AVAILABLE NOTE AS N/A)
YES WAS THE FACILITY OR DWELLING INSPECTED FOR SIGNS OF SEWAGE BACK UP?
YES WAS THE SITE INSPECTED FOR SIGNS OF BREAK OUT?
YES WERE ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,LOCATED ON SITE?
YES WERE THE SEPTIC TANK MANHOLES UNCOVERED, OPENED,AND THE INTERIOR OF THE
TANK INSPECTED FOR THE CONDITION OF THE BAFFLES OR TEES,MATERIAL OF
CONSTRUCTION,DIMENSIONS,DEPTH OF LIQUID,DEPTH OF SLUDGE AND DEPTH OF SCUM?
YES WAS THE FACILITY OWNER(AND OCCUPANTS IF DIFFERENT FROM OWNER)PROVIDED
WITH INFORMATION ON THE PROPER MAINTENANCE OF SUBSURFACE SEWAGE DISPOSAL
SYSTEMS?
THE SIZE AND LOCATION OF THE SOIL ABSORPTION SYSTEM(SAS)ON THE SITE HAS BEEN
DETERMINED BASED ON:
YES NO
YES EXISTING INFORMATION. FOR EXAMPLE,A PLAN AT THE BOARD OF HEALTH.
NO DETERMINED IN THE FIELD(IF ANY OF THE FAILURE CRITERIA RELATED TO PART C IS
AT ISSUE, APPROXIMATION OF DISTANCE IS UNACCEPTABLE) [3 10 CMR 15.302(3)(b)]
REVISED 6/15/2000 PAGE 5 OF 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PROPERTY ADDRESS:549 OSGOOD ST.
OWNER:MARY F.CHARLES
DATE OF INSPECTION:NOV 2.2001
FLOW CONDITIONS
RESIDENTIAL:
NUMBER OF BEDROOMS(DESIGN): NUMBER OF BEDROOMS(ACTUAL):
DESIGN FLOW BASED ON 310 CMR 15.203(FOR EXAMPLE: 110 GPD X#OF BEDROOMS):
NUMBER OF CURRENT RESIDENTS:
DOES RESIDENCE HAVE A GARBAGE GRINDER(YES OR NO):
IS LAUNDRY ON A SEPARATE SEWAGE SYSTEM(YES OR NO): [IF YES SEPARATE INSPECTION REQUIRED]
LAUNDRY SYSTEM INSPECTED(YES OR NO):
SEASONAL USE(YES OR NO):
WATER METER READINGS,IF AVAILABLE(LAST 2 YEARS USAGE(GPD)):
SUMP PUMP(YES OR NO):
LAST DATE OF OCCUPANCY:
COMMERCIAL/INDUSTRIAL
TYPE OF ESTABLISHMENT:DAY CARE CENTER
DESIGN FLOW(BASED ON 310 CMR 15.203): 330 GPD
BASIS OF DESIGN FLOW(SEATS/PERSONS/SQ.FT,ETC.):N/A
GREASE TRAP PRESENT(YES OR NO):NO
INDUSTRIAL WASTE HOLDING TANK PRESENT(YES OR NO):NO
NON-SANITARY WASTE DISCHARGED TO THE TITLE 5 SYSTEM(YES OR NO):NO
WATER METER READINGS,IF AVAILABLE:UNAVAILABLE
LAST DATE OF OCCUPANCY/USE: CURRENT
OTHER(DESCRIBE):N/A
GENERAL INFORMATION
PUMPING RECORDS
SOURCE OF INFORMATION:DIRECTOR/CHAIRMAN
WAS SYSTEM PUMPED AS PART OF INSPECTION(YES OR NO):NO
IF YES,VOLUME PUMPED: /A/A GALLONS-HOW WAS QUANTITY PUMPED DETERMINED?SIZE OF TANK.
REASON FOR PUMPING:N/A
TYPE OF SYSTEM
YES SEPTIC TANK,DISTRIBUTION BOX,SOIL ABSORPTION SYSTEM
NO SINGLE CESSPOOL
NO OVERFLOW CESSPOOL
NO PRIVY
NO SHARED SYSTEM(YES OR NO)(IF YES,ATTACH PREVIOUS INSPECTION RECORDS,IF ANY)
NO INNOVATIVE/ALTERNATIVE TECHNOLOGY. ATTACH A COPY OF THE CURRENT OPERATION AND
MAINTENANCE CONTRACT(TO BE OBTAINED FROM SYSTEM OWNER)
NO TIGHT TANK ATTACH A COPY OF THE DEP APPROVAL
N/A OTHER(DESCRIBE):
APPROXIMATE AGE OF ALL COMPONENTS,DATE INSTALLED(IF KNOWN)AND SOURCE OF INFORMATION:
SYSTEM WAS INSTALLED 1975 DIRE TOR
WERE SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE(YES OR NO):NO
REVISED 6/15/2000 PAGE 6 OF 11
. SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C
SYSTEM INFORMATION(CONTINUED)
PROPERTY ADDRESS:549 OSGOOD ST.
OWNER:MARY F.CHARLES
DATE OF INSPECTION:NOV 2.2001
BUILDING SEWER(LOCATE ON THE SITE PLAN)
DEPTH BELOW GRADE: 33"
MATERIAL OF CONSTRUCTION: 4" CAST IRON 40 PVC OTHER(EXPLAIN)
DISTANCE FROM PRIVATE WATER SUPPLY WELL OR SUCTION LINE:N/A
COMMENTS: (CONDITION OF JOINTS,VENTING,EVIDENCE OF LEAKAGE,ETC.)
THERE WAS NO SIGNS OF LEAKAGE IN OR AROUND PIPE SOILS WERE CLEAN AND DRY.
SEPTIC TANK: YES (LOCATE ON SITE PLAN)
j DEPTH BELOW GRADE: 24"
MATERIAL OF CONSTRUCTION: YES CONCRETE METAL FIBERGLASS POLYETHYLENE OTHER
(EXPLAIN):
IF TANK IS METAL,LIST AGE IS AGE CONFIRMED BY A CERTIFICATE OF COMPLIANCE(YES OR NO)
(ATTACH A COPY OF CERTIFICATE)
DIMENSIONS: 81 X 5'W X 5'H OUTLET INVERT @ 48"= 1000 GAL
j SLUDGE DEPTH: 10"
DISTANCE FROM TOP OF SLUDGE TO BOTTOM OF OUTLET TEE OR BAFFLE:24"
SCUM THICKNESS: <2"
DISTANCE FROM TOP OF SCUM TO TOP OF OUTLET TEE OR BAFFLE: 5"
DISTANCE FROM BOTTOM OF SCUM TO BOTTOM OF OUTLET TEE OR BAFFLE: 14"
HOW WERE DIMENSIONS DETERMINED: SLUDGE JUDGE.ROD,AND RULER
COMMENTS(ON PUMPING RECOMMENDATION,INLET AND OUTLET TEES OR BAFFLES CONDITION,STRUCTURAL
INTEGRITY,LIQUID LEVEL AS RELATED TO OUTLET INVERT,EVIDENCE OF LEAKAGE,ETC.):THE LIQUID LEVEL
WAS @ NORMAL HIGHT.THERE WAS NO SIGNS OF LEAKAGE IN OR AROUND AREA,SOILS WERE CLEAN AND
DRY.THE INLET AND OUTLET ARE LATTERAL BAFFLES AND THEY SHOW SOME SIGN OF WEAR AND DECAY
GREASE TRAP:
NO (LOCATE ON SITE PLAN
DEPTH BELOW GRADE:
MATERIAL OF CONSTRUCTION:
-CONCRETE-METAL-FIBERGLASS--.POLYETHYLENE
(EXPLAIN) CONCRETE METAL FIBERGLASS POLYETHYLENE OTHER
)
DIMENSIONS:
SCUM THICKNESS:
DISTANCE FROM TOP OF SCUM TO TOP OF OUTLET TEE OR BAFFLE:
DISTANCE FROM BOTTOM OF SCUM TO BOTTOM OF OUTLET TEE OR BAFFLE:
DATE OF LAST PUMPING:
COMMENTS(ON PUMPING RECOMMENDATION,INLET AND OUTLET TEES OR BAFFLES CONDITION,STRUCTURAL
INTEGRITY,LIQUID LEVEL AS RELATED TO OUTLET INVERT,EVIDENCE OF LEAKAGE,ETC.):
REVISED 6/15/200 PAGE 7 OF 1 I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(CONTINUED)
PROPERTY ADDRESS:549 OSGOOD ST.
OWNER:MARY F.CHARLES
DATE OF INSPECTION:NOV 2.2001
TIGHT OR HOLDING TANK:NO(TANK MUST BE PUMPED AT TIME OF INSPECTION)(LOCATE ON SITE
PLAN)
DEPTH BELOW GRADE:
MATERIAL OF CONSTRUCTION: CONCRETE METAL FIBERGLASS POLYETHYLENE OTHER
(EXPLAIN)
DIMENSIONS:
CAPACITY: GALLONS
DESIGN FLOW: GALLONS/DAY
ALARM PRESENT(YES OR NO):
ALARM LEVEL: ALARM IN WORKING ORDER(YES OR NO):
DATE OF LAST PUMPING:
COMMENTS (CONDITION OF ALARM AND FLOAT SWITCHES,ETC.):
DISTRIBUTION BOX: YES (IF PRESENT MUST BE OPENED) (LOCATE ON SITE PLAN)
DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT: 0" DEPTH BELOW GRADE: 30"
COMMENTS (NOTE IF BOX IS LEVEL AND DISTRIBUTION TO OUTLET EQUAL,ANY EVIDENCE OF SOLIDS CARRYOVER,ANY EVIDENCE OF
LEAKAGE INTO OR OUT OF BOX,ETC.):
THE D-BOX SHOW SIGNS OF DECAY AND SHOW SIGNS OF SOILD CARRYOVER AND
LEAKAGE IN AND
OUT.SOILS WERE CLEAN AND DAMP THERE'S ONE INLET AND ONE OUTLET ALL ORENGEBERG
CONSTRUCTION.
PUMP CHAMBER:NO(LOCATE ON SITE PLAN)
PUMPS IN WORKING ORDER(YES OR NO):
ALARMS IN WORKING ORDER(YES OR NO):
COMMENTS (NOTE CONDITIONS OF PUMP CHAMBER,CONDITION OF PUMPS AND APPURTENANCES,
ETC.):
REVISED 6/15/2000 PAGE 8 OF 11
II
. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(CONTINUED)
PROPERTY ADDRESS:549 OSGOOD ST.
OWNER:MARY F.CHARLES
DATE OF INSPECTION:NOV 2.2001
SOIL ABSORPTION SYSTEM(SAS): YES(LOCATE ON SITE PLAN,EXCAVATION NOT REQUIRED)
IF SAS NOT LOCATED EXPLAIN WHY:
TYPE:
LEACHING PITS,NUMBER:
LEACHING CHAMBERS,NUMBER:
LEACHING GALLERIES,NUMBER:
YES LEACHING TRENCHES,NUMBER,LENGTH: ONE LINE,YW X 40'L
LEACHING FIELDS,NUMBER,DIMENSIONS:
OVERFLOW CESSPOOL,NUMBER:
INNOVATIVE/ALTERNATIVE SYSTEM TYPE OF TECHNOLOGY:
COMMENTS(NOTE CONDITION OF SOIL, SIGNS OF HYDRAULIC FAILURE,LEVEL OF PONDING,DAMP SOIL,
CONDITION OF VEGETATION,ETC.)
THE LINE IS ORENGEBERG CONSTRUCTION AND IN FAIR CONDITION THERE WAS NO SIGNS OF FAILURE OR
BRAKEOUT IN OR AROUND AREA.THERE WAS NO SIGNS OF WETLAND VEGETATION IN OR NEAR SYSTEM
CESSPOOLS: NO(CESSPOOL MUST BE PUMPED AS PART OF INSPECTION)(LOCATE ON SITE PLAN
NUMBER AND CONFIGURATION:
DEPTH-TOP OF LIQUID TO INLET INVERT:
DEPTH OF SOLID LAYER:
DEPTH OF SCUM LAYER:
DIMENSIONS OF CESSPOOL:
MATERIALS OF CONSTRUCTION:
I INDICATION OF GROUNDWATER INFLOW(YES OR NO):
COMMENTS(NOTE CONDITION OF SOIL, SIGNS,OF HYDRAULIC FAILURE,LEVEL OF PONDING,CONDITION OF
VEGETATION,ETC.):
PRIVY:NO(LOCATE ON SITE PLAN
MATERIALS OF CONSTRUCTION:
DIMENSIONS:
DEPTH SOLIDS:
COMMENTS(NOTE CONDITION OF SOIL, SIGNS OF HYDRAULIC FAILURE,LEVEL OF PONDING,CONDITION OF
VEGETATION,ETC.):
REVISED 6/15/00 PAGE 9 OF I1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(CONTINUED)
PROPERTY ADDRESS:549 OSGOOD ST.
OWNER:MARY F.CHARLES
DATE OF INSPECTION:NOV 12001
SKETCH OF SEWAGE DISPOSAL SYSTEM:
PROVIDE A SKETCH OF THE SEWAGE DISPOSAL SYSTEM INCLUDING TIES TO AT LEAST TWO PERMANENT
REFERENCE LANDMARKS OR BENCHMARKS. LOCATE ALL WELLS WITHIN 100 FEET. LOCATE WHERE PUBLIC
WATER SUPPLY ENTERS THE BUILDING.
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REVISED 6/15/2000 PAGE 10 OF I 1
e
A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(CONTINUED)
PROPERTY ADDRESS:549 OSGOOD ST.
OWNER:MARY F.CHARLES
DATE OF INSPECTION:NOV 2,2001
SITE EXAM
SLOPE-NO
SURFACE WATER-NONE
CHECK CELLAR-NONE
SHALLOW WELLS-NONE
I
ESTIMATED DEPTH TO GROUNDWATER 6'+APPROX FEET
PLEASE INDICATE(CHECK)ALL THE METHODS USED TO DETERMINE HIGH GROUNDWATER
ELEVATION:
N/A OBTAINED FROM SYSTEM DESIGN PLANS ON RECORD-IF CHECKED,DATE OF DESIGN PLAN
REVIEWED:
! YES OBSERVED SITE(ABUTTING PROPERTY/OBSERVATION HOLE WITHIN 150 FEET OF SAS)
YES CHECKED WITH LOCAL BOARD OF HEALTH-EXPLAIN:
NO CHECKED LOCAL EXCAVATORS,INSTALLERS-(ATTACH DOCUMENTATION)
YES ACCESSED USGS DATABASE-EXPLAIN:
YOU MUST DESCRIBE HOW YOU ESTABLISHED THE HIGH GROUND WATER ELEVATION:
WHILE DIGGING IN YARD LOCATING SYSTEM WE DUG NEAR SYSTEM AT DEPTHS OF 6'AND THERE
WAS NO SIGNS OF HIGH SEASONAL GROUND WATER.THERE WAS NO SIGNS OF WETLAND
VEGETATION OR ABBUTTING PROPERTY'S WELLS WITHIN 100'FROM SYSTEM.
REVISED 6/15/2000 PAGE 11 OF 11
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CONSTRUCTION
92 GLENN STREET
LAWRENCE , MA. 01843
978 - 687 - 3059
FACSIMILE TRANSMITTAL SHEET
TO W S rROM: hqv
COMPANY: DATE:
FAX NUMBER TOTAL NO.OF PAGES INCLUDING COVER:
PHONE NUMBER: SENDER'S REFERENCE NUMBER:
RE: YOUR REFERENCE NUMBER-
URGENT
UMBERURGENT ❑FOR REVIEW ❑PLEASE COMMENT ❑PLEASE REPLY ❑PLEASE RECYCLE
NOTES/COMMEN'T'S:
I
I
Dave Nall
Outside Plant Supervisor
New England-North
Comcast
Comcast Cable Communications,Inc.
92 Glenn Street
Lawrence;MA 01843
Tel:978.685.0258 Ext.3589
Gonfrdendality Notice
OThis communication is only for the use.of the intended recipient and may contain information that is privileged,confidential
or otherwise protected from disclosure. If you are not the intended recipient or the employee or agent responsible for
delivering this communication to the intended recipient,you are hereby notified that any reading,distribution or copying of
this communication is strictly prohibited. If you have received this communication in error,please notify us by telephone
and then destroy this communication in its entirety. Thank you.
rax from tlb—Lf—tlti tlL:nyp Yg: L
05/12/2008 MON 15:48 iR3570 CLAWIR 0001
*****************
*** TX REPORTt***
*****************
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JOB NO. 4873
DEPT. ID 1234
ST. TIME 05/12 15:47
PGS. 1
SEND DOCUMENT NAME
TX/RX INCOMPLETE -----
TRANSACTION OR 19786889542
ERROR -----
l
Town of North Andover NoRry
Building Department
1600 Osgood Street �,��
Horth Andover MA 04845 . ."` ,� A
,Tel: 978-658-9645 Fax: 978-688-9542 �
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ADDRES owocdke 9,0 m,e f PP4,
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i AT(ON OF-PROPERTY T9 DEMOLISH <09 ..
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DEPARTMENT S1GN4)FFS
DEPT.OF PUOLIC WORKS -WATgR- S
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GAS
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FIRIS
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EXTERMINATOR
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_ corporat on
706 Broadway Street
Lowell,MA 01854
Termination natwn Letter
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06 May 2008
To Whom It May Concern:
S&R Corporation will be demolishing 549 Osgood Street,North Andover,MA.This
structure is a vacant 3 family.Barns'#1  will be demolished also.It is now owned
by the Edgewood Retirement Properties.
,
Accordingly,please consider this a formal request for your office to immediately
disconnect and/or remove any and all services,piping,service drops,litres, cables,
meters,etc.of any kind on this property.Time is of the essence. Thank you for your
cooperation in the matter.
Should you have any questions,please do not hesitate to contact me,Thank you.
Sincerely,
Wesle umont
Cell: (603)234-1152
Title:Assistant Project Manager
Tel. 978-441-2000 - Fax 978-441-2002 -
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706 Broadway Street
All Lowell,MA 01854
Tei; (978)441-2000
Main Fart (978)4412002
corporaf-ion
_ Estimating Fax: (978)441-3002
i
Facsimile Transmittal Sheet
U' Comcast(Dave Hall) From: Wesley Dumont
a Fax: (978)687-3059 Pages: 2
Phom (978)685.0258 Date: 5/6/2008
Re: Request far Termination of Ser*es cc:
X Urgent ❑For Review ❑Please Comment 11 Please Reply 0 Please Recycle
•Comments:
Please sign and fax back. Thank you.
0
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t'ax from 85-27-88 82:09p pg: 5
` Town of North Andover `` pORTH
i Building Department
1600 Osgood Street
North Andover MA 01846
Tel: 978-688-9545 Fax: 978-688-9542
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DEMOLITION F BUILDING AFFIDAVIT �RATWO w ��
j 9sSgCHUSE�
' DATE
MERS NAME&AQ2LE9ail- pp'6 poed; !a,—
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LOCATION OF P PER Y DEMOLI
DESCRIP O ,
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0 R' ME&ADDR S
p (n_ E&a lWat4 Q(Q el L cxo ,_ f /)!`SSS
DEPARTMENT SIGN OFFS • '
O DEPT. OF PUBLIC WORKS -WA
I TER: SEWER:
EPT OF CONSERVATION EA TN DEPT:Se 9c 0 Well
• GAS
ELECTRIC
• EPM k
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1.Grlll�Sf
TAXU
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POLICE
FIRE
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EXT
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DUMP — OFF STREEr
DI E MBE
DATE R 'D
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iDoc-"dembl bn of WNW affided
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Location
No. / Date
NORTH TOWN OF NORTH ANDOVER
• `9 Certificate of Occupancy $
t ; : Building/Frame Permit Fee $ oCi
Foundation Permit Fee $
sACHuse
Other Permit Fee $ ...
Sewer Connection Fee $
Water Connection Fee $
w TOTAL
pp / Building Inspector
j 3 1 3 R05/27/99 1T':37 25.E (?AID
Div. Public Works
'i
PERMIT NO. J APPLICATION FOR PERMIT TO BUILD********NORTH ANDOVER, MA
mAil NO. 3 I,OTNO- 2. RECORDOFO%VNERSHIP DATE BOOK PAGE
ZONE SUR DIV. LOT NO.
LOCATIO
N_ 0 PURPOSE OF BUILDING c
ONVNER'SNAME yI/) NO.OF STORIES SIZE
F.
OWNER'S AD RESS 1 6 O BASEMENT OR SLAB
ARCIIITECT'S+NAME SIZE OF FLOOR TIMBERS 15P 2ND 3RD
BUILDER'S NAME ''K l h vi 'lam O SPAN
DISTANCE TO NEAREST BUILDING EJ DIMENSIONS OF SILLS
i
DISTANCE FROM STREET DIMENSIONS OF POSTS `
DISTANCE FROM LOT LINES-SIDES REAR DIMENSIONS OF GIRDERS
AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW Q SIZE OF FOOTING Iz`X �� 6 X
IS BUILDING ADDITION S MATERIAL OF CHIMNEY �Ld.l3i
IS BUILDING ALTERATION ` IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEIVER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTUCTIONS 3. PROPERTY INFORNIATION LAND COST
EST. BLDG.COST J Q —
PAGE I FILL OUT SECTIONS 1-3 EST.BLDG. COST PER SQ. FT.
EST. BLDG.COST PER ROOM
ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING SEPTIC PERMIT NO.
ATFACHED GARAGES M1IUST CONFORM TO STATE FIRE REGULATIONS 4. APPROVED BY:
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR BUILDING INSPECTOR
Y .
DATE FILED OWNERS TEL# 4.98 — 73 ZZ
CONTR.TEL# _97X'- g$7_g6-
CONTR.LIC#
00(1,8
LFEE $
E OF-OWNER OR AUTHORIZED AGENT >4�Z
ANTED
19
Revised 5/5/99 3M
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FORM U - LOT RELEASE FORMA
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
*****************************APPLICANT FILLS OUT THIS SECTION*************
APPLICANT_ Cti&d4 J (t'(,� PHONE
LOCATION: Assessor's Map Number PARCEL
SUBDIVISION LOT (S)
STREET (s Ob ST. NUMBER
*************OFFICIAL USE ONLY***********************************
64- oil Atj
RECOMMENDATIONS OF TOWN AGENTS:
CONSERVATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
COMMENTS (/;)O �Q III l 00/
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FOOD INSPECTOR-HEALTH DATE APPROVED
DATE REJECTED
SEPTIC INSPECTOR-HEALTH DATE APPROVED
DATE REJECTED
COMMENTS
PUBLIC WORKS -SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR. DATE
Revised 9197 jm
IAORTH
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ORATED
ImElk BOARD OF HEALTH
Food/Kitchen
PEK� R� q� IT T Septic System
� BUILDING INSPECTOR
THIS CERTIFIES THAT... ..... ..Ar... ......../....�.....er.. r..� .... V S
.... ........................................................... Foundation
has permission to erect...` !.6........ !.`!..... buildings on .....6 ...[..�......0.cv. .40c)D........
.%T....... Rough
® � � � Chimney
to be occupied as... ............ ............................................ ................... .... ...............................................................................
provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
F
PC �l: f MWIT EX-P- ES Ii\1 6 NAAN_fl-IS Final
U V I-ESS C NS T t1UM ION 5T,,� ,,TS ELECTRICAL INSPECTOR
Rough
..... .. .... ...... ....... ..................
Service
BUILDING INSPECTOR
Final
�)CcuptvlcPermit Requr'ved i0 GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. l3urner
Street No.
SEE REVERSE SIDE Smoke l)et.
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CONSTRUCTION SUPERVISOR IC NSi
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Number Expires: Birthdate:
&a CS. 096818 04J30J2000 04J30J1946
Restricted To; 00
I ROY A °SKINNER-
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OF"”' 100 GEORGETOWN RD
BOXFORD, MA 01921
GJ � rlt� ilk, f
HOME IMPROVEMENT CONTRACTOR
Registration 100302
} Type - PARTNERSHIP,
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Expiration 06/15/00 I
SKINNER BROTHERS
I Roy A. Skinner
4 l� i.nda Ave
ADMINISTRATOR
Reading MA 01867 1=
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THE COMMONWEAL TH OF MASSACHUSETTS
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d TOWN OF NORTH ANDOVER L
In accordance with the Massachusetts State Building Code,Section.106,5 th s
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CERTIFICATE OF INSPECTION
IS ISSUED TO... FAMILY COOPERATIVE PRESCHOOL, INC
I CERTIFY thatl have inspected the PREMISES.:.......... known as.. FAMILY'COOPERATIVE PRESCHOOL
located,-549-05GOOD STREFC in the TOWN of NORTH ANDOVER
COUNTY OF...................ESSEX..............................Commonwealth of Massachusetts The means of egress
are sufflIcient for the following number of persons.,
BY STORY
Simy Capacity Story . Capacity story capacity Staly Capadty �
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Place of Assembly Capacity Location Place of Assembly Capacity ,
Location
or structure or structure ,
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1S-r-FLOOR 24 AV Arm a, Q tl�
549=00 10/5/20000 10/2001
Certificate Number Date CerGficatie Issued Date Certificate Expires Building Official
i
No. Z (/ Date
RT
TOWN OF NORTH ANDOVER
i 9 l
+ ; : Certificate of Occupancy $
�'�b'••°''<�' Building/Frame Permit Fee $
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Foundation Permit Fee $
I Other Permit Feed-t $
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TOTAL $ Z//o
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TOWN OFNORTHANDOVER �� VC
27 CHARLES ST C':�-61 r
APPLICATION FOR-CERTIFICATE OF INSPECTION
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Date (� Fee Required(Amount) d
O No Fee Required
Accordance with the provisions of the Massachusetts State Building code, Section 108,15, I hereby apply fo,
Certificate of Ins
cdon for-the below-named preWses--located-at-the followingad&Rss:
Street and
Number UT" Lj ( �` ;'�' Vq
Name of C In
Premises m 15d
Purpose for which Pre ses is
UsedPf Do ( _
Licenses (s) or Permits) Required for-the P-r-emises by-Other-Governmental Agencies:
License or Permit Agency
e✓✓ICCLS
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Certificate to be issued to
Address L5 ss 3�. Te ephone o D
Owner of Record of Buil tng
Address
Name of Present Holder of Certificate
Nam of Agency, ' any
SIG TURF OF RSONS TO WHOM CERTIFICATE TITLE
IS ISSUED OR fflS A-UTHOIRIZED AGENT
DA E
INSTRUCTIONS:
11) Make checkpayable tomTown North Andover
2) Return this application with your check to: .Ouddina,Dept i-
27 Charles Street, North Andover MA 01845
PLEASE NOTE:
Application form with accompanying FEE must be submitted for each building or structure or part thereof to be cert
3) Application and fee must-be-received before-the cer#fcate will-be Issued.
4) The building officials shall be notified within ten (10) days of any change in the above information.
CERTIFICATE# E"IRATIONDATE:
FORM SBCC-3-74 REFISED-2199 jmc
TOWN OF NORTH ANDOVER INSPECTOR'S NAME
OFFICE OF THE INSPECTOR OF BUILDINGS MICHAEL MCGUIRE
INSPECT40N-REPORT-FORM
CLASSIFICATION PASSES INSPECTION yes 0 no 0 DATED
OWNERtM
BUILDING NAME OR-NO. -- -
STREET LOCATION
TYPE OF OCCUPANCY Z" �Cafe , AW. 0 -Gym Apt. .0
School 0 Common Victualer's 0 Liquor Place,of Assembly
Other
OCCUPANCY NUMBER fi dude-steries # aM-occupam jw4loor use4tever-se side -
EX�ISST.TLNGS
Ll[ICT.-S!GN , yes ,
- 'no 0
LIGHTED EXIT SIGNS operable , l es -no _0
EMERGENCY LIGHTING SYSTE M �operable dry cell 0 wet cell 0
SPRINKLER SYSTEM operable 0 gage pressure yes .0no 0
SMOKE DETECTOR operable yes--�no
FIRE ALARM SYSTEM -expiratien-date
ANSUL SYSTEM yes 0 no$�
FIRE ALARM SYSTEM operable municipal 0 yes 0 no 0
ELECTRIC EQUIPMENT PROPERLY PROTECTED esA'�no 0
EGRESSES LAWFULLY DESIGNATE unobstructed e 0
STAIRS PROPERLY RAILED ye�f no 0
HALLS AND STAIRWAYS LIGHTED yes,-A'no D
RADIATOR GUARDS yAA�no 0
COMPLIES HANDICAPPED PERSONS LAWS -yes -no -0
FIRE RESISTANT CURTAINSORDRAPERIES
HO HEATED T�f-� � � Fay. rl:\_i L:.v_':v ;e
s no
BOILER ROOM CONDITION
VENTILATION
UTILITY ROOM - CLOSETS ,QJ
NUMBER OF GRADE FLOOR MEANS OF EGRESS DOORWAYS
NUMBER OF SEPARATE STAIRWAYS ACCESSIBLE PER STORY
SHOPS
FOR INSPECTOR USE ONLY Revised 2/99 SMC
05/12/2008 MON 15:48 FAX 0001/001
Town of North Andover
Building Department o �° 46
1600 Osgood Street
North Andover M1 O'845 }o
'Tel: 978-U8-9545 Fax: 978-688-9842
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