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HomeMy WebLinkAboutBuilding Permit #778-2017 - 1490 GREAT POND ROAD 5/1/2018 e f f ORTH ' BUILDING PERMIT o�N "tio TOWN OF NORTH ANDOVER �2 y APPLICATION FOR PLAN EXAMINATION � 4 ^. Permit No#: Date Received 12- 0. � �P"'•cy 4U AA I's C1465 Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION _490 Cln°Af Pte►J C Q �a rSs � Print PROPERTY OWNER �I�"ll Print 100 Year Structure yes Q MAP OJZ PARCEL:L)L)7-p,1 ZONING DISTRICT: Historic District yes <f�D Machine Shop Village yes. no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building .(tune family Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition _ ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands 111f Watershed District ❑Water/Sewer - -- DESCRIPTION OF WORK TO BE PERFORMED: sem,t I yyI rg,,��► ZZx 3� d ne MA Identification- Please Type or Print Clearly ,77q , S-�3! OWNER: Name: ("i Phone: Address: L !0 G1r'e P6z-,d ?6�')1,114 sContractor Name: Phone: .s'G a '3/s� (e�� Email: r(( ,�+�1 QHS enf;�e cv�►-f Cq) Add4��nress: o So t3 �( L�w �n u 1lAa • D��y3 f Supervisor's Construction License:_0 l0 330 Exp. Date: o' - 17 Home Improvement License: l O) Exp. Date: ® 2 - 13 " 1 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: $ 3 n5-0 - FEE: � 315 33 Check No.: it, Receipt No.: NOTE: Persons con ratting with unregistered contractors do not have access to the guar my fund — _�— -- — r 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 OTE: 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 Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) ;rF Engineering Affidavits for Engineered products OTE: 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 Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) .� Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: 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 I NOTES and DATA— (For department use) ;J e - l53 _4 fProC-Q�. c� &jai j ❑ Notified for pickup Call Email Date Time Contact Name = Doc.Building Pennit Revised 2014 T �-- -- 1 { Stamped Plans ❑' Plans Submitted L� Plans Waived ❑ Certified Plot Plan TYPE OF SEWERAGE DISPOSAL Swimming pools Public Sewer Tanning/Massage/Body Art ❑ ❑ Tobacco Sales ❑ Food Packaging/Sales Well ❑ Private(septic tank,etc. ❑ permanent Dmmpster on Site THE FOLLOWING SECTIONS FOR OFFICE U FORME ONLY INTERDEPARTMENTAL SIGN ��'PLANNING & DEVELOPMENT Reviewed On jjqj Signature_Vb11j_L_ COMMENTS W ,�` OVCf CONSERVATION Reviewed on -Signature 1 COM ENTS EALTH Reviewed on Si nature COMMENTS fes-' V Y Zoning Decision/receipt submitted yes 'Zoning Board of Appeals:Variance, Petition No: Ol Plrnning Board Decision: Comments In ; Conservaiion Decision: Comments tha Drivewa Permit mu; Wafter &..Sewer Connection/Si nature Date DPW Town Engineer: Signature: Located 384 Osgood Street r VF(RE.DEPARENT - Temp)Dumpsteromsite byes ocatediat 124CStreet FireiDepartment:.Signature/date -.. COMMENTS - - Location No. �� I Date l o, III • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ --�� Foundation Permit Fee $_�` Other Permit Fee $ _ TOTAL $ Check# 7 4 Building Inspector Uvti+ Plans Submitted Plans Waived ❑ Certified Plot Plan Stamped Plans r TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/MassageBody Art El Pools [ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM /PLANNING & DEVELOPMENT Reviewed On 'Signature_ COMMENTS VCONSERVAXTION Reviewed on ,D-11 SignatureAj COM ENTS �, EALTW Reviewed on Signature COMMENTS O ' 4 "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: FIrRE DEP Located 384 Osgood Street rIAR�TMENT�'E Temp�kDumpster;on�site :,lyes tno _ 'I Locatetl of i12,4� i ` - r -� — �-�•- = y. -� -_ -...,�. i ...• ,. Mam Street' ,. .. ':� ,` 'Fire{Departsi:gnatureldafe; COMMENTS. , Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: 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) mW �L�,j Z 1LP i"l �5 3 O'J-Q-J ��, - Pr1 a ❑ Notified for pickup Call Email Date Time Contact Name f Doc.Building Permit Revised 2014 NORTFt '9 own of a ndover No. - � 2 h o h ver, Mass, F4. I (p 2-60 [OC MICA... 1• ��AO a�V .9 OArED S V BOARD OF HEALTH PERMIT T L D Food/Kitchen Septic System THIS CERTIFIES THAT ........... .�[,�. ?.R!+ .!.... 94!�r./„ G s„ BUILDING INSPECTOR L C1�....... eG. - �� Foundation has permission to erect-......................... buildings on ..... .... YY .�s.'........................................... • Rough to be occupied as ...2.2.. %. �i.. ......��*.�. .. ..�... .. �form ... .. ......�............................. Chimney provided that the person accepting this permit shall in every respect coo tefi terms of thea application pp Final on file in 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI T RT Rough Service ...............� . ..... ... Final k_ _UILING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Burner Street No. Smoke Det. 70 South Broadway 45 Route 125 Lawrence,MA 01843 Kingston,NH 03848 Tel: 978-688-8307Aidf Tel:603-642-9909 10 Fax: 978-688-1949T SINCE 1975 Fax:603-642-9906 providing a full line of services and supplies fully licensed and insured www1amilypoolsonline.com Name C91 a�C' t So/ 0i I M Ate C Date Z r i�D l�' Address 14 90 (.ire J Po City LJOri 1Ao0(.Jvr-ttate lltl� Zip Dfs-4. Home Phone C1- ,11 57 - 5b3l Work Phone Cell-717q Sj3- 4F 12- Add'I# Nit Cross Street/Directions Estimated Start Date Estimated Completion Date We propose to furnish and install one�,GinAunite 2 3.9 S-+ . W^11 k d o 8` swimming pool for the sum of$ -?,3,)�S7) THIS PRICE INCLUDES: •Normal Excavation up to 8 hours on day of dig •Manual vacuum cleaner kit •Waterline Tile((i) •Backfill and Sub-Grade up to 3 hours •3-Step stainless ladder •Liner Choice 1 e_a •UndarwaterWhitetight`12 Volt •Rope and floats •Test Kit Z •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 pod size) •Coping fZ fJt_C-__ •Pressure testing of plumbing during construction •Leaf net •Steps •Ten Year Plumbing Guarantee(see specifications) •Wall brush -Handrails— Transferable HandrailsTransferable Lifetime Structural Warranty •Extension pole •Filter (plumbed no more than 25ft from pool) •Pump&motor �� 1 THIS PRICE DOES NOT INCLUDE: `I t� T r r�I " •Any plumbing over 25ft from pool.Additional runs are not recommended but would be at a cost of$ _Z per foot per line. •Machine time in excess of that specified above.Additional machine time to be billed at$ ((OS" including machine,operator,and laborer,due with second pool payment. •All hours of trucking will be charged at$_ %)_per hour per truck due with second pool payment •Any dumping costs incurred for disposal of ledge,large rocks,garbage,stumps buried or otherwise,building materials,unsuitable or nonstructural soils,or any unforeseen material that must be removed. •Removal of ledge or large rocks by way of a Starr bit,chipper,or blasting. •Additional fill,if necessary,for proper backfill or reshaping of hole,supply or spreading of loam,reseeding of grass. •Patio,fence,retaining wall,or any accessory items other than noted on contract •Electrical wiring,fuel connections,heater venting,fuel storage tanks or permits. •Repair or replacement of sprinkler systems or any buried items such as well lines,drywells,leach fields,electrical lines,cables,etc.that are damaged during construction. •Costs due to water or soil conditions(ex.clay,peat,live sand,excessive rock,etc.)requiring a stone pack of the hole.The stone pack will be at an extra charge of$ 0 U minimum to $ maximum and at the discretion of the job supervisor.Additional machine time and/or materials necessary to rectify such a condition will be at a cost over and above the stone P ack nd will be quoted by the job supervisor. •Water to fill pool. Initials CUSTOMERS MUST SUPPLY: •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: T t j( +#4pj k A 4 b — Z D c{,t-.. C 14 L'J4* Sra� S 1�r ?•� n ,f.r o f/n l( l�l�C. .- be ✓?tr J, (A OPTIONS: TOTALS: Diving Board ( ) r Basic Pool Price $ Z3 Z Solar Cover ( ) '•'— Additional Pool Lighting 3 Options $ p G S06 Heater Environpool Plus,8 hd+2 surface ( ) �a���� t � SUBTOTAL $ -31 -7<-a Additional Floor Heads ( ) 191-2- Polaris I1-2-Polaris Vac-Sweep 5%Sales Tax $ Polaris retrofit only ( p ) TOTAL $ Z '7 y'Z wimod ench n enor Finish ( ) Less 10%Deposit $ Spa ( ) '." 74 7 4 . Automated Control System ( ) Balance of Contract �rS $ Salt Chlorine Generator (�>r-,,, j P(oT ) ?-► G° t ``) Other PAYMENTS: 113 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. .22t,W BUYER 4a- date 11 1/16 2J Ito SELLER � "'°^� date CO-BUYER date CER77FIED PLOT PLAN PROPOSED POOL IN NORTH ANDOVER. MASS. MIDDLESEX SURVEY INC. LAND SURVEYORS 131 PARK STREET NORTH READING, MA. 01864 SCALE.• 1"- 60' DATE.• DEC. 24, 2016 0' 60' 120' 180' � o X00 V U13 "4 s azOB.>5- � ,V ,QoAO 4y � 501 , ' 00' z ya o 75 46' REFERENCE; yero BK. 14014 PG. 233 (DEED) ,� F° PL. NO. 7646 (PLAN) cb �� ! ELEV. (ASSUMED) IN LOT 6 X ^h LOT 7 ry 44,417fsf /14ry� ti LOT 5 ZONE.- R1 MIN SETBACKS PROPOSED POOL FRONT 30' LOCA 170N t SIDE 30' REAR 30' <.�• 1 c^� POOL FRONT 30' �- SIDE 10' REAR 10' ODER 1400' TO LAKE COCHICHEWICKIr� - DETAIL SCALE.- 1a- J0' 130. LOT 21 82.08 15 W \`` ��P�j"OF*S'S' ALPHONSE yGN Zo o LOT 22 v HALOEY 4 I CER77FY THAT 7HE EXIS77NG DWELLING IS NO. 31312 LOCATED AS SHOWN.,)6�2� RFs cis>��° DA 7E.- 12/24/16 RegS'°NaL LAS SJ i er d L Surveyor NO. 1840 North Andover MIMAP January 23, 2017 3521iGREAT POND RD I� orloo ,} y�' 1527 GREAT POND �Jfff. A 15-11rGREdT POND RD �1: �+ 062.0-0021' r /J/ 04 062.0-0020 _ 062.0-0015 or-,'062!0-0074 ,062.0 0071 062.0-0076. J� � � �'.>✓r'r �` �` +' +,r / 14.75 GREAT POND RD � 1535 GREAT POND RD �► 00F 00' 710 L loGREAT POND RD or41 14 OF 1 01 001 ,. 4, F' 1478 GREAT PONWRD '` 062.0-0027 062:0-0030,r 06 Z.o-00'X29' Xoo 062:0`00314`' t` �/,. ✓�+ ! s' �, rYiiJ REAT POND.R tJ` 1510 GREATtPOND RD F/ 1.490 GREATtPOND¢RD J / 062.0-0099 .+I GAMPION�R 040, 0001, .OF 01 oe 062:0-0098 0r, or 00 062:0-0097 1 C'•AMBION.RD, 34 CAMPIOWRD f !� 42�OCHICHEWICK>DR 600, 4 COCHICHEWICK DR 1 062000079 000, el '. hickewk Road _. .or coo ,�.. , 10 062.0-0080 �'� /l.+7�' r / ,r✓✓ 4WCAMPION RD 062.0-009,4/ 6i�COCHICHEWICK DR062 p0-0091 � - _63.0=0092 Q MVPC Bo Zoning Overlay Zoning Q Adult Entertainment DISMc . Busine s 1 District ®Municipal Boundary Q Machine Shop Village Ove 12Busine 5 2 District Horizontal Datum:MA Stateplane Coordinate System,Datum NA083, —Rail Line ®Watershed Protection Dist D Busine s 3 District Meters Data Sources:The data for this map was produced by Merrimack Interstates ©Historic Mill Area i Busine s 4 District AORTN Valley Planning Commission(MVPC)using data provided by the Town of = Interstate ©Medical Marijuana ■Gene Business District Of ,,a° r•'4,r North Andover.Additional data provided by the Executive Office of Major Road Q Downtown Overlay District O Plann Commercial Dev ? s�� •e OO Environmental ARairs/MassGIS.The information depicted on this map is 0 Historic District Corrid Development Dist 3• L for planning purposes only. y It may not be adequate for legal bounds Roads U Osgood Smart Growth(40 IB Conid Development Dist Q _,- •-- - Q g boundary definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER t i Easements Hydrographic Features O Corrid Development Dist F p MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING Industri I 1 District ❑Parcels Streams t Y THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY ` Industri 12 Dist6U x s ,7 ♦ OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT Wetlands Industri 13 District c .� ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF 13 Industri I S District �� C Exempt Lands Reside ce 1 District 't/,f °��rrp• 4g THIS INFORMATION ' Reside ce 2 District SSACHUSE a Reside ce 3 District de ce 4 DisfiU 1"=124 ft " .de ce 5 DisfiU YYY de ce 6 District ,a a esidential District -VFFI WALL PUOL SYST-rAl TURNBUCKLE BRACE 22'X 38'-3" KIDNEY STRAIGHTWALL-, CUSTOMER: RAYSTATE CAMBRI'DGE "YOOR SIGMTURE ACGIDYPUDIAS XCEPITAW.. 2' DWG#:GS-BD97 DATE; 1012112002 REV.- TAG: FAMILY POOLS-ANSON STEEL PML PANEL AREA(� sq 6.5,5 1 POUMEYER.101' EST'.Va(US,ria)): THE) TURNBUCKLE ST T :tL31N,01�4 I PIECE ANGLE BRACE CONCRETE FOOTER Pool UFAD EAST PLATE n (7 SMI AW EMBEDDED NUT BRACE 22'4' Lkip [WEDDED- STEEL POOL P.A.ft =cRETEFoolik 2 TEEL P-L T U'NBU c ,PE_ ANGLE BRACE A E VAN E L FOOTER 2 AD-N �SE PLAT E SM, ED 71D '_ ""p STEEL PANEL _.C.E,E F..E N a•wuv PAtiI ST-72mr II TA.. STSDIlik 77 jF T-72011M DECK SUPPORT(OPTIONAI SILL OF KATERMEi _,A kti't ' X t PA 't)Stp It'Radius 0mmh I su stp WR Ir 7; l�_12sVl_Fq-_#L _ _ _)_L_ 11 PW Is"x .;tl Pnl 36"Plain 1200"RPI Sd Nil 42"x SR)k-vwse ST 01118 SfiPjil S4"x 11'R GRACE j HARDWARE-OPITONS I jiFT�ia- I s"Pni 60"x v-'u'R QTY PART'141JMMR DESCRIPTION Stl Pfd 72"x VA jj;;;s—e - 15 $T-300ISF9 �Bw Tumb�urk'77e7—B-.:r—:agc-c-ceq(Dif4-Req 3 ST-720I128 SH Prd 72"x 11'8_-2-iCIT 15 ST-lW4W Sic Do3dman Plate I ST-72 stj Pill 72 x IVR Lk _(ff F�Ag rWf4WA 0112RL ftt-2 14,zb L5 ST-1WOEMB p AG* pni 72'.r*r-&,R-2 Pit) Brare4 Sm ip W-2012 Hdw NDANvcl_x:_-��77E�E is ST_lw6Ds 9T_8rc0erk Sli_iicrt 7_dv., hu ST-%G:! PWn-2 Ribs '2018 L t I IS0 Pni 1 ImW_Z002 I!n S p TlAdIliQNi.I TM Ca"WE M PORIULZIPWIA12 WAMW.ALMLY. 0 No WHO Sint 011:11V311"m SigRage Must te Permanandy adached a mund the padmeter of the pooloevm. "W-sknla-t OPP=, i . The Commonwealth of Massachusetts M . F Department of IndustrialAceldents 1 Congress Street,Suite 100 Boston,MA 02114-2017 °t www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le 'bl SAddrName(Business/Organization/Individual): A-M l(3 US- Address: ess: 0 gy I wv,1 City/State/Zip: LAkO N-vl") AA-ISS V f W12 Phone#: 11 Are you an employer?Check&e appropriate box: Type of project(required): 1.QJI am.a.employerwith employees(full and/or part-time).* 7. A.New construction .2.FI am a sole proprietor,or partnership and have no employees working for me in 8. FJ Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑DemoIition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. : 12.[]Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ # 13.E]Roof repairs • These sub-contractors have employees and have workers'comp.insurance. 6.n We are a corporation and its offigers have exercised their right of exemption per MGL c. n 14. Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information Homeowners who subriiif#his 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 and state whether or not those entities have employees. If the sub-contraciors aveemployees,Ikey must provide their workers'comp.policy number. Iain an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: �Le1 • �� _ Policy#or Self-ins.Lie.#: //WWG f Expiration Date: Q -31 -17 Job Site Address: (Loo City/State/Zip: A4455 . 4>17Y�— Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains saandpenalties ofperjury that the information provided above its true and correct. Signature: � Le� '�-�'q-- je Date: -K_ y 20(7 Phone#: a�7 F-1.T ZZ 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'compensation affidavit 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 confirmation 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 permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/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 permits 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia FAMIPOO-02 DKULICK ACORO CERTIFICATE OF LIABILITY INSURANCE FDATE 1/6/206/20MM/D /7 17 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER License#1780862 NAMITACT HUB International 299 Ba lardvale Street England PHONE FAX ( ) (A/c,No,Ext:(978)657-5100 (pIC,N,: 976 888-0038 Wilmington,MA 01887 I-A SS; INSURERS AFFORDING COVERAGE NAIC# INSURERA:ValleY Forge Insurance Company 20508 INSURED INSURER B:Safe Insurance Company 39454 Family Pools&Patios Inc. Bill 8 Cindi Gianopoulos INSURER c:Wesco Insurance Company 25011 70 S.Broadway INSURER D: Lawrence,MA 01843 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR NSR TYPE OF INSURANCE ADDL SUER JIM WVD POLICY NUMBER POLICY EFF POLICY EXP LIMBS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR 6015920803 09/19/2016 09/19/2017 DAMAGE TO RENTED 100,000 X PREM S S a occurrence) $ X Blanket Add'1 Ins. MED EXP(Any oneperson) $ 5,000 PERSONAL&ADV INJURY 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑JEC F1 LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: B AUTOMOBILE LIABILITY Ea eINED SINGLE LIMIT $ 1,000,000 ANY AUTO 3947232 12/31/2016 12/31/2017 BODILY INJURY Perperson) OWNEDX SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ X HIRED X NON-OWNED PROPERTY AMAGE AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ 1DEDT1 RETENTION$ C S COMPENSATION AND EMPLOYERS'LIABILITY X STAT E ETH WWC3246415 12/31/2016 12l31I2017 E.L.EACH ACCIDENT $ ANY PROPRIMT ER/PARLUDED XECUTNE Y N 500,000 QFFICER/MEMBER EXCLUDED? NIA 500,000 (Mandatory in H) E.L.DISEASE-EA EMPLOYEE $ If yes,descrlbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-PO ICY LIMIT500,000 A Property 6015920803 08/19/2016 09/19/2017 vrs limits A Repl Cost 6015920803 09/19/2016 09/19/2017 $1000 ded DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more apace is required) Workers Compensation has Blanket Waiver of Subrogation,as required by executed contract. Workers Compensation has Blanket Waiver of Subrogation,as required by executed contract.Work in NY is excluded;new construction of 10+units is excluded. Re:Gabe&Sandal!Mater,1490 Great Pond Rd CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation = 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvemerit Contractor Registration Type: Supplement Card P'-1 Registration: 118204 FAMILY POOLS & PATIOS INC ' ' i `: �� ; N Expiration: 02/12/2019 70 S. Broadway E " Lawrence, MA 01843 . E t � �- Update Address and return card. Mark reason for change. sco, r.• 20M-05/11_ El A dress ❑ zm wal C7 Employment ❑ Lost Card ,�a C-�-/!)C TFr1T1[)110�7[u8�[�II[OC��CCIJJC(C✓[t[JCI�3 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Supplement Card before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 118204 02/12/2019 10 Park Plaza-Suite 5170 Boston,MA 02116 FAMILY POOLS&PATIOS-INC GLEN WIGGIN . 70 S.Broadway r'2 Lawrence,MA 01843 Undersecretary Not valid wi ho . nature cr Office of Consumer Affairs and Business Regulation 10 dark Plaza _ Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Re qistration: 118204 FAMILY POOLS& PATIOS INC Type: supplement Card Expiration: 2/13/2017 GLEN WIGGIN 70 S. BROADWAY _.------- ._.. --- —.. LAWRENCE, MA 01843 21,M-os-11Update Address and return card.:Nlark reason for change. Address Renewal Employment 7Lost Card "it- - Lfi,.ce of Consumer Affairs&Business Regulation i VIE IMPROVEMENT CONTRACTOR License or registration valid for individul use only eke i before the expiration date. If found return to: g stration: 118204 Office of Consumer Affairs and Business Regulation _ Expiration: 2713/2017 Type: 10 Park Plaza-guile 5270 `At>riILY POOLS&PATIOS INC Supplement Card Boston, 11A 02116 GLEN VJIGGIN y BRp.ADWAY /� MA 01843 n.. %2 . rsecretary -- Not valid without 3s' t. t�� I�lI�S.ar7iC�D �' '�� �-....u..,.,._-..y...,..,_.�.m,........�...-._...w...,...,..,....s............. - of`u'it.`jf„tln`lt. {? 1� c'Vr'?rF Sy s'ai"tCuai'd tallia3'ira> iit't " - liaifi:a'i -leerls(a: CS4DIO330 .p KK 77pp /!��AA yy��7x��d��{a/l• LAWRENCE y t•.fiTt7f7?iS�^I'@'1't�Qf4 a..XPi rai:J:i 437/19/2017