380 Septic Repair Loan NORTHAMPTON SEPTIC REPAIR PROGRAM
PAYMENLREQTJTSITION
fur
CONSTRTICTION ADVANCE
Septic System Repair Project Cost Summary:
Address: 380 Chesterfield Rd Leeds City Contract# 164-99
Total Project Cost: S13 790.00
Owner's affidavit
As owner of 180 Chesterfield Rd., I hereby request that a Construction Advance Payment of 56.895 00
Address
(this represents Y: of the construction costs of 513,790.00)be issued so that my contractor,Tark
Excavating,can begin the required repair work on my failed septic system. It is understood that the
final payment will be made after the complete septic system has been installed and the Board of Health
has issued a certificate of compliance.
Print name: Beatrice Dickinson�
Signature: pf",ja�/ 164;e,,,uyc)
Address: 21-.7.v? 7/ Gd, 4e8 Pigs ,C.)
Contractor's affidavit
As of ,I do hereby agree that I will accept
Company Name
$6.895.04 (one half of the quoted construction project cost)as advance payment for installation of an
approved septic system at 380 Chesterfield Rd It is understood that the final payment will be made
after the complete septic system has been installed and the Board of Health has issued a certificate of
compliance.
Print name:
Signature:
BOARD OF HEALTH
MEMBERS
NTHIA DOURMASHKIN,R.N.,Chair
ANNE BORES,M.D.
Rosemarie HarparIs,R.N.,MPH
ETER J.McERLAIN,Health Agent
(413)587-1214
FAX(413)587-1264
VIEMO
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
BOARD OF HEALTH
210 MAIN STREET
NORTHAMPTON,MA 01060
TO: Mr. &Mrs. Michael Abbatessa
FROM: Peter McErlain, Health Agent
DATE: lane 30, 1999
SUBJECT; Application for a Septic Repair Loan
Asst. City Solicitor Joseph Cook has advised me that in order for the City to pay out on the
septic repair betterment loan for your property at 380 Chesterfield Rd.,you must show that
you own the property by submitting updated versions of the following:
• the betterment loan application forms,
• the contract and
• the payment requisition
Enclosed please find the blank forms for each of the items listed above. In addition,I've
included a copy of the application forms submitted by Mrs.Dickinson,you'll probably be
able to use some of the information from her forms Please note that you must use the
current registry of deeds information which resulted from your recent purchase of the
property.
Please complete the forms, contracts, and the requisition where appropriate and return all of
the information to the Board of Health office.
Once the Board of Health,and other city agencies have signed the contracts we will be able
to authorize the pre-construction loan payment.
Please feel free to contact me with any questions concerning this matter.
Thank you for your cooperation.
BOARD OF HEALTH
MEMBERS
JOHN T.JOYCE,Chairman
ANNE BORES,M.D.
CYNTHIA DOURMASHKIN,R.N.
PETER J.M<ERLAIN,Health Agent
(413)587-1214
FM(413)587-1204
MEMO
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
BOARD OF HEALTH
210 MAIN STREET
NORTHAMPTON,MA 01060
TO: Northampton Septic System Repair Loan Programm Participants
FROM: Peter McErlain,Health Agent
DATE: February February 3, 1999
SUBJECT: Requisition for an Advanced Construction Payment
Enclosed please find a requisition form for an advanced payment for the construction of your
new septic system.
h1 order for the city to issue the first payment towards the cost of replacing your failed septic
system, you(and your contractor)must sign the requisition. By doing so,you agree to accept
an initial payment equal to the engineering costs and one half of the construction costs of
your project. In addition, it indicates that you are aware that the remaining construction
payment will be made after the installation of the new septic system,the issuance of the
certificate of compliance,and the submittal of a bill for the outstanding balance of the
completed construction work to the Board of Health.
Both you and your contractor must sign this the requisition.Return the completed form to the
Board of Health office so that your advanced payment can be processed.
Please contact me at the Board of Health office with any questions.
Thank you. U2 q
IJ � ISOD, �
/ 04
NORTHAMPTON SEPTIC REPAIR PROGRAM
PAYMENT REQUISITION
for
CONSTRUCTION ADVANCE
septic System Repair Project Cost Summary:
Adress: 380 Chesterfield Rd ,Leeds City Contract# 164-99
'otal Project Cost$13,790.00
owner's affidavit
s owner of 380 Chesterfield Rd.,I hereby request that a Construction Advance Payment of$6.895.00
Address
this represents Y:of the construction costs of$13,790.00) be issued so that my contractor,Tark
;xcavating can begin the required repair work on my failed septic system. It is understood that the
nal payment will be made after the complete septic system has been installed and the Board of Health
as issued a certificate of compliance
tint name:Beatrice Dickinson
ignature:
.ddress:
'ontractor's affidavit
is of ,I do hereby agree that I will accept
Company Name
6.895.00(one half of the quoted construction project cost)as advance payment for installation of an
pproved septic system at 380 Chesterfield Rd,It is understood that the fuel payment will be made
fter the complete septic system has been Installed and the Board of Health has issued a certificate of
ompliance.
Tint name:
■ignature:
NORTHAMPTON SEPTIC REPAIR PROGRAM
PAYMENT REQUISITION
far
CONSTRUCTION ADVANCE
Septic System Repair Project Cost Summary:
r Address: 380 Chesterfield Rd., Leeds City Contract# /./&-BO
Total Project Cost: $14,600.00
Owner's affidavit
As owner of 380 Chesterfield Rd.,I hereby request that a Construction Advance Payment of$7,300.00
Address
(this represents % of the construction costs of$14,600.00) be issued so that my contractor,Tark
Excavating, can begin the required repair work on my failed septic system.It is understood that the
final payment will be made after the complete septic system has been installed and the Board of Health
has issued a certificate of compliance. ��,•-r / n �n,L�,.
Print name: 4 /_ ' ` - % - _5u i�j/ t iTati /Ct L. /i�J" `_'•"fess'2
Signature: pp�y �i/1 estate: //�,�/C/ ✓
Address: (574/ �(q"t i(�/��-/� / cad
Leeds /ru- aies3
Contractor's affidavit ��n
t ,'\
As 4 � of •il LX o hereby agree that I will accept
Company Name
$ 7,300.00(one half of the quoted construction project cost) as advance payment for installation of an
approved septic system at 380 Chesterfield Rd.It is understood that the final payment will be made
after the complete septic system has been installed and the Board of Health has issued a certificate of
compliance.
BOARD OF HEALTH
MEMBERS
NTHIA DOURMASHKIN,R.N.,Chair
ANNE SURES.M.D.
IOSEMARIE KARPARIS.R.N.,MPH
DETER J.McERLAIN,Health Agent
(413)587-1219
FAX(413)587-1264
To:
From:
Date:
Re:
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
BOARD OF HEALTH
210 MAIN STREET
NORTHAMPTON,MA 01060
City Auditor Mike Lyons
Health Agent Peter McErlain
December 15, 1999
Void Septic Repair Contract for 380 Chesterfield Rd.
This memo will confirm that the betterment contract(# 164-99) with Beatrice
Dickinson for septic repair at 380 Chesterfield Rd. is void. Mrs. Dickinson sold
the property to her daughter who subsequently entered into a separate
betterment contract(#40-00) for septic system repair.
Please contact me with any questions concerning this matter.
Thank you.
FORM 3A - CERTIFICATE OF CO:MPLIA:SCE
COMMONWEALTH OF ASSACHUSETTS
Board of Health
MA.
Fee
CERTIFICATE OF COMPLIANCE -
Description of Work: ❑ Individual Component(s) geComplete System
•The undersigned hereby certify that the Sewage Disposal System;
Constructed ( 3, Repaired 9( Upgraded 0, Abandoned ( )
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the
approved design plans/as-built plans relating to application No-
dated /D—<D
Installer
Designer:
Date
t ' 9 < Aball/l/i
Approved Design Flow_ (gpd)
wiL[
nspector
The issuance of this permit shall not be construed as a guarantee that the ���/�
function as designed.
system will
DEP APPIIOVED FOLM 5/96
Northam
Northampton Septic System Repair Loan Proaram
Bill for Repair of
Septic System
on Board of Health
210 Main Street
Northam ton.,MA 01060
Date: August 9, 1999
From: Michael&Tan a Abbates
380 Chesterfield. Rd
Leeds MA 01053
Cit Contract ti 40-00
Repair of failed septic system at_380 C hes in accordance with approved
plans.
Total approved cost-----------"----`-`-
$ 14,600.00
Advanced Construction Payment requested: 57.300.00
Note: the remaining 57,300 of the project cost will he paid upon completion of the
septic system installation and issuance of the Certificate of Compliance
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPRO\'A
PAGE 5 OF
c) a shared system :s not feasible:
- 1Ca-Ep -`Shcf✓on!5 AC-% Ft� E(% v,e nIEz 1s Iveysui✓6H / 61E%CE
d) connection to a sewer is not feasible:
�) FvH/cq/;LL-
10i An application for a disposal system construction permit, including all required attachments
(e.g. plans & specifications, site evaluation forms), must accompany this application. Is the
DSCP application attached? yes_no
11) Certification
"I, the facility owner, certify under penalty of law that this document and all
attachments, to the best of my knowledge and belief, are true, accurate, and
complete. 1 am aware that there may be significant consequences for submitting
false information, including, but not limited to, penalties or fine and/or
imprisonment for knowing violations."
Facili owner's signature
to/1u,s,-yr..)
eet (Q_ kare/o f/✓SGnd
Print Name //�� (y)/
Thir Name of prepargf
6 7 - 5aq /
Telephone X & address of preparer
Date
NOTE: Title 5, 310 CMR 15.403(4), requires the system owner or operator to submit to the
Department a copy of the local upgrade approval upon issuance by the Hoard of Health and prior
w commencement of construction.
Ot,APPROVED PORN
Northam on Se tics stem Re air Loan Pro•ram
Bill for Repair of
Septic System
Northampton Board of He
210 Main Street
Northampton 01060
Date: August 27, 1999
From Michael&Tanya Abbatessa
380 Chesterfield,Rd.
Leeds,MA 01053
Bill t2
Repair of failed septic system at 380Cerf eld Rd.. Leeds in accordance with
approved plans.
Repair work was completed and a Certificate of Compliance was issued on August 26,
1999
Total approved cost
Advanced Construction payment(8/9/99)
spount 9 'id.,
$14,600.00
7 ann.n°
7; 0.f1