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HomeMy WebLinkAboutBuilding Permit #709-11 - 10 MOLLY TOWNE ROAD 4/22/2011 TOWN OF NORTH ANDOVER f APPLICATION FOR PLAN EXAMINATION Permit NO: 1 Date Received Date Issued: Z— IMPORTANT:Applicant must complete all items on this page LOCATION iD M0�. yTOc� l � 61° Ori) dyer, A. Print PROPERTY OWNER I3 r�6(A k Ct1 a c S 60- Print MAP NO: Y 0 PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes �ZO TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ( New Big �d One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑.Septic p Well 0 Floodplain q Wetl_'ands,❑ . WatersliedlDist6—t' ❑ Water/Sewer i DESCRIPTION OF WORK TO BE PERFORMED:. .. -fes l� 9-r' , x o Li (Identification Please Type or Print Clearly) OWNER: Name: -z-Y- 0 I r1 Zk1,P 14fWC \one: D15�,?g'3 c-e4 Address: 4 of CONTRACTOR Name: S Phone: _3 iS'd c ':? - Address: �D c� t�G�d(1�ah L CA qi�e-i Supervisor's Construction License: n(0130 Exp. Date: 07 - 1 ' 7i,) 1 Home Improvement License: U no Exp. Date: 0)- - (3- -LOU ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ A'7 8 ft FEE: $ •Z Check No.: 13- /- Receipt No.: NOTE: Persons contracting with unregistered contractors do not have acAttogu randyfund ignature ofAgent/Ow.ner � Signature_of contracto Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan J Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer 1� Tanning/Massage/Body Art ❑ Swimming Pools Well ❑ Tobacco Sales ❑ Food Packaging/Sales ElPrivate(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed.on ': It Si nature• ,11 (256�-- COMMENTS /U �,,� ��� 1�n C 00 ` i HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature; Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: I i ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use Ll Notified for pickup - Date Doc:.Building Permit Revised 2008mi Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit i all cases if a variance or special permit was required the Town clerks office must stamp the decision from the Board of Appeals iat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording Lust be submitted with the building application Doe: Doe.Building Permit Revised 2008mi Location eoi, C/ No. Date Z/j f NaRTh TOWN OF NORTH ANDOVER � w a Certificate of Occupancy $ ;�s', Nis<�' Building/Frame Permit Fee $ Foundation Permit Fee $ ? Other Permit Fee $ TOTAL $ Check # 3 24bCi Building Inspector i t a 92C „ Office of Consumer Affairs&B sincss Regulation License or registration valid for individul use only 1 _. HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 118204 Type: Office of Consumer Affairs and Business..Regulation Expiration: 2/13/2013 10 Park Plaza-Suite 5170 • ,� Private Corporation FA ILY POOLS&PATIOS INC' Boston,MA 02116 WILLIAM GIANOPOULUS S. BROADWAY LAWRENCE,MA 01.843 Undersecretary Not valid without signature i 1 I t ry= Massachusetts - Department of Public Sxfcth Board of Buildin,; Rc;;ulations and Stand.trds Construction Supervisor License License: CS 10330 T Restricted to: 00 WILLIAM C POULOS 70 S BROADWAY LAWRENCE, MA 01843 Expiration: 7/19/2011 ('uuuui, iuuc•r Tr#: 1306 i 1 1 1 providing a full line of services and supplies fully licensed and insured www.familypoolsonfine.com L �� zo1 o Name i1 t'w --?— 1�t�a — Address 10 .Date city cit � State li�v'� Zip�1I r< Home Phone 1[w2�_k8W Work Phone Cell "-J A3Add3l# Cross Street/Directions 4 Suc/' ALelvr VV Estimated Start Date Estimated Completion Date We propose to (furnish and install on In gunite � x 4-0 "A! 0-`'-P swimming pool for the sun'!of$ 13CS eo_ THIS PRICE INCLUDES: Normal Excavation up to 8 hours on day of dig Manual vacuum cleaner kit Waterline Tile(6•) Backfill and Sub-Grade up to 3 hours 3-Step stainless ladder Liner Choice I 1 Underwater White Light 120 Volt Rope and floats Test Kit Steel Reinforcing per Engineered Plans for gunite Initial balancing chemicals Surface skimmer(s) _ Steel Structure per Engineered Plans for vinyl 8 to 12 Wk supply of maintenance chemicals Dual Main Drains Over-Flo Line for added protection (supply depends on pool size) Coping Pressure testing of plumbing during construction Leaf net Steps -' C r �c I(, � •Ten Year Plumbing Guarantee(see specifications) Wall brush Handrails --es -L t-i-- -Transferable Lifetime Structural Warranty Extension ole Filter �� rr7(plumbedotmoret•Pump&motor � THIS PRICE DOES NOT INCLUDE: -Any plumbing over 25ft from pool.Additional Wins are not recommended but would be at a test of$--_�S per foot per line. Machine lime in excess of that specified above.Additional machine time to be billed at$_" including machine,operator,and laborer,due with second pool payment All hours of trucking will be charged at$_- 1 5 per hour per truck due with second pool payment Any dumping costs incurred for disposal of ledge,large rocks,garbage,stumps buried or otherwise,building materials,unsuitable or nonstructural soils,or any unforeseen material that must be removed. Removal of ledge or large rocks by way of a Starr bit,chipper,or blasting. Additional fill,if necessary,for proper backfill or reshaping of hole,supply or spreading of loam,reseeding of grass. Patio,fence,retaining wall,or any accessory items other than noted on contract. Electrical wiring,fuel connections,heater venting,fuel storage tanks or permits. Repair or replacement of sprinkler systems or any buried items such as well lines,drywells,leach fields,electrical lines,cables,etc.that are damaged during construction. Costs due to water or soil conditions(ex.clay,peat,live sand,excessive rock,etc.)requiring a stone pack of the hole.The stone pack will be at an extra charge of$_* minimum to $__ Z V_maximum and at the discretion of the job supervisor.Additional machine time and/or materials necessary to rectiry such a condition will be at a cost over and above the stone Fack and will be quoted by thejob supervisor. Water to fill pool. CUSTOMERS MUST SUPPLY: — Initials Access for all trucks and equipment •Building and Electrical Permits or assume the costs necessary to obtain such permits. Water and electric necessary for construction of pool •Customer must water cure Gunite shell for 7 to 10 days if applicable. Water to fill pool immediately upon interior finish NOTES: - �•c^U�t�i d�/1 yy __ I r { �Y�vP/W,✓� D"V+� It_K c;�r..,rr� „" �J 7 j� Vl r. s [� SW i\n-1" f`mac 1 L%�.%�-•! �.h( µc:�G-�L'.tz.-•\ OPTIONS: 1 J TOTALS: Diving Board Solar Cover ( ) Basic Pool Price $ f svc f Additional Pool Lighting 3 �(� -� � ) C-c-* -_ ( ) _ Options $ Heater Environpool Plus,8 hd+2 surface SUBTOTAL $ 7 J21 Additional Floor Heads ( ) V•7,5; Polaris Vac-Sweep ( ) yt+� _S,'SalesTax $ Polaris retrofit only ( ) ` TOTAL $ �2 8 t SwimouUBench ( ) interior Finish ( ) "— Less 10%Deposit $ �� Automated Control System ( ) Balance of Contract $ i •7 4- Salt Chlorine Generator Giber S•rz�' (j PAYMENTS:V3 EXCAVATION 113 BACKFILL+EXTRAS 113 SYSTEM START-UP The buyer hereby agrees to pay,in full,the total amount of this transaction upon start-up of the installed pool.Your salesman or job supervisor will meet with you prior to excavation at which time all decisions including pool size,shape,elevation,liner print,and all options must be final.Changes after this date will be subject to extra charges,where applicable,and will result in unavoidable delays.You,the Buyer,may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.Credit card payments not accepted on contract amount. BUYER date SELLER date C0 BUYER ' SIX 1'\� \s J i`� L ,t i r} I date STEEL WALL POOL SYSTEM 20' X 40' OVAL DWG#: GS-1020 I DATE: 2/6/2008 REV: A PAGE 2 0111 40'-1 5/8" TURNBUCKLE BRACE 2, g� ST-300100R ST-9602 ST-4800 ST-9602 STEEL POOL PANEL 3'-4" ST-480100R TURNBUCKLE T PIECE ANGLE BRACE 4-0' CONCRETE ST-720101 R DOTER x Pool DEADMAN EASE PLATE R10'-0" 44'-9 7/8" 28'-3 3/8" S ANE 12'-0" 20'-0" ST-720101 RL EMBEDDED NUT BRACE R6'-0" CUP EMBEDDED NO STEEL POOL PANEL ST-720101 R 4'-0" 1'-0 CONCRETE FOOTER 2'POOL EASE ST-48010OR ST-30010OR ST-9602 ST-4800 ST-9602 STANE RACES& DECK SUPPORTS AT PANEL JOINTS AS SHOWN DECK SUPPORT(OPTIONAL) 4'-0"+�--6'-0" 14'-0" .DIS SAY THIS DOCUMENT IS FOR ILLUSTRATIVE PURPOSES ONLY. REDANGER ^ Alpha 3 Mfg.makes only those representations which are stated in its written warranty.Any other representations,statements,or contracts made by the dealer/contractor to the customer regarding ai SULT IN SERIOUSattributable to the dealer/contractor only.The dealer or contractor who sells or installs your pool is an indepen dant contractor and is not an agent or employee of Alpha 3.The construction methods illi NO DIVING INJURY OR DEATH. to normal ground conditions.There may be additional precautions and/or methods of construction.The responsibility is the contractor's.-A safety line,with buoys,is to be permanently attached 1'-0"t change.-Different methods and precautions may be dictated by various ground conditions.This is to be determined by and is the responsibility of the contractor who is not an agent of the manufactur Signage must be permanently attached around the be done in accordance with all federal,state and local building codes,as well as A.N.S.I./N.S.P.I.suggested standards.-BOTTOM SPECIFICATIONS MUST MEET OR EXCEED A.N.S.I./N.S.P.I/A.P.S.P.R perimeter Of the pool, signage must be permanently attached to the entire perimeter of the pool.See instructions with signage.-IT IS NOT RECOMMENDED TO USE DIVING AND/OR SLIDING EQUIPMENT ON RES `lit, a W-1 A to ; 40'-1 5/8" 13..0., ST-300100R ST-9602 ST-4800 ST-9602 'i-4 5T-480100R ST-720101R ST-720101R ST-720101R R10'-0" R10'-0" 44'-9 7/8" � 20'-0" ST-720101 RL 28'-3 3/8"r �� FS-9694RBW" R6'-0" 4' f l,. ST-720101R ST-720101R ST-48010OR ST-30010OR ST-9602 ST-4800 ST-9602 ST-720101R RACES& DECK SUPPORTS AT PANEL JOINTS AS SHOWN 3' 4" L 3'-4" A 4'-0" 6 0" 14'.0"' 16'-1 5/811 hI iCIIMI NI IS FOR ILLUSTRATIVE PURPOSES ONLY. /\ Alpl �:t MI!I makes only those representations which are stated in its written warranty.Any other representations,statements,or contracts made by the dealer/contractor to the customer regarding any components produced b Ib l nils llrinnlrli ro Ihn dealer/contractor only.The dealer or contractor who sells or installs your pool is an independent contractor and is not an agent or employee of Alpha 3.The construction methods Illustrated !Inrund conditions.There may he additional precautions and/or methods of construction.The responsibility is the contractor's.-A safety line,with buoys,is to he Permanently at P Y Alpha 3 are linnllrr D11101mit methods and precautions may be dictated by various ground conditions.This is to he determined by and is the responsibility of the contractor who is not an here are suggestions and apply only P y [ached manufacturer a the shallow side component the point to first slope IJill "In m:r;or dance with all federal,state and local building codes,as well e i structions ith suggested standards.-BOTTOM SPECIFICATIONS MUST MEET OR EXCEED A.N.S.I./N.S.P.I./A.P.S.P.RECOMthe MENDED STANDARDS'NO DIVI �''ilrn�l''rnir.t Inr Irermanently attached to the entire perimeter of[he pool.See instructions with signage.-IT IS NOT RECOMMENDED TO USE DIVING AND/OR SLIDING EQUIPMENT ON RESIDENTIAL POOLSparts.-Installation is to NG' \lM�ttifx3: I I EASEMENT j OQ- X I < � V Z `., ZONING DIMICT R-2 MIN. AM = 21,780 S.F. L.4:q c G-�S MIN. LOT WIDTH = 100' MIN. FRONTAGE = 100' 1 MIN. FRONT SETBACK = 20' MIN. SIDE SETBACK* = 20' # MIN. REAR SETBACK = 20' (* — THE STRUCTURE MAY HE PLACED UPON A SIDE LOT LINE WITHOUT A SIDE SETBACK, PROVIDED THAT THE ADJACENT LOT TO WHICH THE ZERO SETBACK IS LOCATED HAS THE REQUIRED SIDE YARD SETBACK.) FOUNDATION LOCATION PLAN OWu f M LO m APBY-LIDS AV MTECr WHO COMMUC70 OW CERTff?C4 I W©OLS NOT CONSWO ANY Onffi? ��SWH AS � Mr,&MaM= ones a- W CLIENT: NORTH ANDOVER REALTY ZW 070 IBE i U50 By Tff Cceff MR A" THIS CERTIFICATION IS MADS' AND UNITED WRHTM POWSSM OF CHMS10M t SERGI AMC TO THE ABOVE CLIENT_ FURNERMW Teas Dmwm is THE Gopyaomm PRapmy OF CHRrsTuxM &S W W- AND ANY UNAUTHORIZED USE Is T.vtEs NO RESPONSMttTY LOCATION: MOLLY TOW RD, MOM M r: NW OR AW INFOR- ANDOVER, MA. Ss � SCALE: f" = 60' DATE: MICHAEL 90 to 915108 � MICHAEL ym CHRISTIANSEN R SER ST. LANs� �8 160 S � X4ML OtWo TEL. 978-373-Dara ®zoDe BY Cjfi?nrMjVSEN& i'N� RAWING NO 97066010 m:Eileer, P. Hart.AAI-Hub Internatlorial New Engi To:blank COI to ins(160334714DO) IG:12 U1110111UNI1-s:c I✓g CllentZ: 53642 FAMILYPOCLI ATE ACORD, CERTIFICATE OF LIABILITY INSURANCE [701110120(MMIUDI1111 THIS CERTIFICATE IS ISSUED A.G.A MATER OF INFORMATION ONLY AND CONFERS NO RIGHT S UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE?GLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:It To cart. tate holder is an 0DITIONAL INSURED,the poi cy,les)must be endorsed. i IVED,su ject to the terms and conditions of the policy;certain policies may require an endorsement.A statement on this certificate doe5 not can-er rights to the certificate holder In lieu of such endorsement(s). PRODUCER ` NAME: HUB International New England 14ONE 978 657-5100 —AX 866-475-7959 299 Ballardvale St E�fA1L DS= ss: Wilmington, MA 01887 ADDRESS: — -- 978 657-5100 I CUSFOMER ED f: NSURERIS)AFFORDING COVERAGE NAIL F INSURED Family Poo!s&Patios Inc. INSURER A:NaUtilUS Ins Co 15418 Cindi Gianopoulos II,4suRER 13:Technology Insurance Co 70 S.BroadWay INSURER C:Acadia Insurance Company 131325 INSURER D:Safety Insurance Co �— Lawrence, MA 01843 ----- — ---_.__- —---- --- .. . -+-- -- - tNSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BE'-OW HAVE BEEN ISSUED TO THE INSURED NAl"4ED ABOVE FOR THE POLICY PERIOD INDICATED.NOTVWI T HSTANCING Atd"REQUIREMEN ,TCRM OR co!mI ION OF ANY CONTRACT OR OTHER DOCUMENT t.M714RESPECT TC wHICH THIS N CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFF' BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL T"E TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICES.LIMITS S.-<'I;dh 10A f HA.4E BEEN REDUCED BY PAM W-110S. + DULrRI POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM!DD!YYYY IIYM!DO,YYYY' LIMITS A GENERAL LIABRITY NN036497 911912010 0911912011'1 EACH OC::URRE!,CE �1,000,000 r AA6k 1 il n X 4^OMN ERCIAI_GENERAL UAR',LIT Y PREM SES r'Ea occu,,an:,1 ,. $100 QO0 ..A'Af5-MADE 1 M D F�:P OCCUR -- tAffr or,=,arsr.^.) $S..00Q X, BUPD Ded:2,6010 PERSONAL P.AD'.'iNJU.`RY 0,000,000 XI SICU Ind GENE;tAL AGGRD A''E_$2,000,000 GE.:,[`L AGGREGAT E LINI-AFTLIES-Eh PRODt)C".>.COifc%Cp.--GG $2,000,00Q P7_ICY ,�FCPRO � LOC � --- $ D AUTOMOBILE LIABILITY , 3947232 213112010 1,2/31/20111 Earecc uED SINGLE_rail T ANYAUTO 1,000,000 IBGDILeIN.JURY:Pe'Pe;cnj £ .ALL OVMED AUTOS I y ( I BODILY;riJ��RY lPe'C�LIQe:ilj $ X'3CHEDULEC AUTOS I PROPERTY DAMAGE $ XHIRED AUTO_ I iPef arddanh X '}ON-C?WNEC AUTOS $ $ UMBRELLA LIAB JL'.�UR SACH E OLL'U REa, - N r CE - $ I EACM LIAB DF i r,1M, I AGGREGA-E $ I._' S-RIA DEDUCT.2- --- t $ B AND MPLLOYOERS'LIASIL TY YIN TWC3259514 213112010 1213112011 T u: s.;-._10-14 ANY PROPRIETOR;PARTNER'EX2C`_MVE UFFH',EP.MEIJBER E.XCLJ')ED1 (5 NIA E LI EA,H ACCIDENT $100,Qf 0 INIaaaatory in NMI IF-F.L—CISE-a SE-En.2M?-.CYE $100,000 If�/a,da,,.rha;ndFr DESCRIPTION OF OPERATIONS oetoty :L.DISEASE-POL11''Llydl- 1$500,000 C Property CFA018008414 11912010 09119/20111 vrs limits a vrs locs Spec Form Re l Cast Ded$1000 DESCRIPTION CF OPERATIONS!LOCATIONS'VEHICLES lACach ACORD 101,Addit,onei Remarks Schedule,if more apace is�ecluiredj CERTIFICATE HOLDER CANCELLATION 10 Days For Non-Payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 3E CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WrTHI THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 1988.2008 ACORD CORPORATION.All rights reserved. ACORD 25(2009!1,19) 1 O f 1 The ACORD name and logo are ragistared marks of ACORD X484414 EH002 i The Commonwealth of Massachusetts r Department oflndustrial Accidents P. Office of Investigations .1 600 Washington Street l;`e?;` Boston,MA 02111 ° .� www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Prinf Legibly Name(Business/Organization/Individual): L t}pelf Address: ID z City/State/Zip: FCk WW"t-2,01Ue M I ' 0 9 4�1 3 Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1. I ama' employer with ZS 4. ❑ I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am,a sole proprietor or partner- listed on the attached sheet. $ � ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.[:] Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance d.ire re u , employees.[No workers' required.] comp.insurance required.] 13.[ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors acid their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: d0MLCA,S �r Policy#or Self-ins.Lic.#:: Expiration Date: 12,-31 -2,04 Job Site Address: 10 I V\D 11t���yJA IC City/State/Zip: � w-r �j 01 Attach a copy of the workers compensation policy declaration page(showing the policy number and expiration date). Failure totsecure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance'coverage verification. I do hereby certif under the pains and penalties ofpesjury that the information provided above is true and coi ect Si nature: « �"`�"` Date: 7,0 14 Phone#: QJI Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or.on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensationaffidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confinnation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any.questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the pennit/license number which will be used as a reference number. In addition,an applicant that must submit multiple-penmit/license applications in.any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future pen-nits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Cammonvrealth of Massachusetts Department of industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4940 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7748 www.mass.gov/dia TOWN OF NORTH ANDOVER G APPLICATION FOR PLAN EXAMINATION Permit NO: I 1 Date Received Date Issued: — -z,— IMPORTANT:Applicant must complete all items on this page LOCATION J© M0j,(y-TC-jA Z h L Pr cVCr, MA. JJ``''__Pri PROPERTY OWNER 13 rt6k 1 k M �t Print ri S (� Print MAP NO: r PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes 6D TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Bak4ng fcg Z One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition 11Other PT Ptc � � .�}Flood'lain tlandsl � atershed D sti ct� µ pliSeD,Well � _1? _ ► DfWi I ®i W - 1Water/,Sewer, DESCRIPTION OF WORK TO BE PERFORMED:. ,° ' LOA (Identification Please Type or Print Clearly) —6 OWNER: Name: u �L.� L �N one: — `) Address: I` , 4t V"� M*SS, of CONTRACTOR Name: ` , . (1 "' Phone: e -3 fa-Ij Address: ' b f e'J Ujaw L cA w R!Eo Ge., M a Si 0i Supervisor's Construction License: p'} 0 3.30 Exp. Date: 0 v Z b f � Home Improvement License: U-01 Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ A`7 6()-o FEE: Check No.: 3L/.�� Receipt No.: l NOTE: Persons contractingwith unregistered contractors do not have access to the gu ran unrd g h'.f ISi nature of�i4 ent/Owneri�'" "'� tSi riature�ofcontr - 9. ---�--_ _yu'actorr -- _. i I ORTH ® O Andover No. LAKE O " dover, Mass., �COCMICHEWICK ��• RATED SS BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System • BUILDING INSPECTOR THIS CERTIFIES THAT........... ... . N..or.c-.,..� ......................... .... ................................................ .. ... Foundation ' "' oun ' has permission to erect........................................ buildings on ....t0............IM011�"'.M.+��,•....... . ...... ..• Bough to be occupied as..&PAW...q0........ .............. Chimney provided that the person accepting this permP rm t���Ji� every respect corffohe 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 Final PERMIT EXPIRES IN 6 ONTHS UNLESS CONSTRU ON ARTS ELECTRICAL INSPECTOR Rough ......... ........... ................................................................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry wall To Be Done FIRE DEPARTMENT -Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det.