28 Perc Test, 2013 CI1"I' OF NORTHAMPTON,
DEPARTMENT OF PUBLIC
1251 Locust Street
Northampton,MA 91060
413-687-1570
Fax 413-587-1576
MASSACHUSETTS 28 MORNINGSIDE DRIVE
WORKS
Trench Permit Number: 2014136
Date Approved: .7�fl/.
Expiration Date: MAO/43
(for City Use Only)
EXCAVATION/TRENCH PERMIT
Puisuant to G.L.c. 82A and 520 CMR 14.00 et seq.(as amend
This permit must be fully completed prior to consideration. Submit completed form with permit fee to
t ► :ee :� a G.' �%! 24. 01
s . w S' lire<e y + pro 1s ens o r .c J j j.` 4.64 appi i i e sections ofthe
Revised Ordinances of the City of Northampton,including,but not limited to,Section 285-21.
Fee:5250 Check#: 6353 Date Issued: 8/30/13
Name of Applicant
RANDY BAKER
Primary Phone#
413-348-6991
Street Address
149 BRIDGE STREET
Emergency Phone#
City/Town
NORTHAMPTON
State
MA
Zip
01060
Email
Name of Excavator
SAME
Primary Phone#
Street Address
Emergency Phone#
City/Town
State
Zip
Email
Name of Property Owner(s)
RICHARD HUMPHREYS
Primary Phone#
413-335-1937
Street Address.
28 MORNINGSIDE DRIVE
Emergency Phone#
City/Town
FLORENCE
State T Zip
MA i 01062
Email
Insurance Certificate#
ON 1~1LE
Policy Expiration Date
Name&Contact Information of Insurer
ON FILE _
Dig Safe##
2013-350-1066
Pp.114,aceia ion?renctt Pe n
Project Description/Location of Work.Provide the following: •
Description of purpose and exact location of proposed work including description of what is to
be laid or repaired in the proposed trench(e.g.waer pipe,sewer pipe,drain pipe,gas-line,
power line,communication lines, etc
or drawing showing all proposed work.
Anticipated Start of Work Daze.
YES
NO
t
.
Check here if Emergency.
Describe.
Work in Public Right-of-Way -
Work on Private Property „ • .
Work within State Layout(If yes,attach State Permit) -
)'Z
Work within 100 ft,of a w eland or 200 it of a strearin or river.•(lf yes,At#arh Pernut)
Work within Floodplain.(If yes,attach Permit)
..../-
Public Water/Sewer/Drain Entry Permit(AttRrh Permit',if available)
•
Driveway Permit(Attach Permit,if available) iti '
28 MORNINGSIDE DRI
Ptn-ect Description/Location of Work.Provide the following:
Description of purpose and exact location of proposed work including description of what is to
be laid or repaired in the proposed trench(e.g.water pipe,sewer pipe,drain pipe,gas line,
n, power line, communication lines, etc
I Sketch or drawing showing all proposed work.
[711 Anticipated Start of Work Date.
ASAP
PERC TEST AND REPLACEMENT OF A FAILING SEPTIC SYSTEM
YES
NO
,..
Check here if Emergency.
Describe.
X
Work in Public Right-of-Way
X
Work on Private Property
X
Work within State Layout(If yes,attach State Permit)
X
Work within 100 ft.of a wetland or 200 ft.of a stream or river.(If yes,attach Permit
X
Work within Floodplain.(If yes,attach Permit)
X
Public Water/Sewer/Drain Entry Permit(Attach Permit,if available) .
X
Driveway Permit(Attach Pem4 if available)