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Home My WebLink AboutBuilding Permit #629 - 1525 Forest Street 3/23/2011TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO:(J 2� Date Issued: ,-2� IMPORTANT: Date Received must complete all items on this LOCATION \,!52-5 Print PROPERTY OWNER Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no �;k,Lo\ \C)S" . '� -- U vUZ—CY)UO <. O Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building JOne family ❑ Addition El Two or more family El Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition Other',\ odplan� ®W4e tlandsl .; eptic?4F -TY WatershedlDist� ict� t ®Water/Sewer '- .. DESCRIPTION OF WORK TO BE PERFORMED: 7 e Identification Please Type or Print Clearly) OWNER: Name: ae-Wke-A. Phone: q'Ll ss S;-<c°Q.4 Address: \S;6 G �tY�° �' 7�� CONTRACTOR Name: S`", �L�� .�Z. Phone:\•1�6C`� Xis 0 Address: lna3 �1 ,ZY� 4,�.� '� -��. �ti• 1� �' ` Supervisor's Construction License: C.S \ala 41--- Exp. Date: Home Improvement License: FS\,( ---3 Exp. Date: ARCHITECT/ENGINEER Phone: Address: g. No !9'- a3- zc)\2 4-\\—,;�o\\ FEE SCHEDULE. BULDING PERMIT. $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ `702, _FEE: $ J�f� 10 ) & S` Receipt No.: Check No.: P cq�> NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Location 7— EA No. Date Of TOWN OF NORTH ANDOVER 0 Certificate of Occupancy $ Building/Frame Permit Fee $ CHU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # /0 / �� 239LO Building Inspector Plans Submitted ❑ Plans Waived ❑ - Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming 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 DATE REJECTED PLANNING & DEVELOPMENT ❑ COMMENTS 9 DATE APPROVED El CONSERVATION Reviewed on I `� t Signature COMMENTS HEALTH Reviewed o I L( j 1I COMMENTS Z�v .rJZ Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Com If 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.: 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 ® Notified for pickup - Date Doc:.Building Permit Revised 2008 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 ❑ 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 ❑ 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 DOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit n 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 lust be submitted with the building application Doc: Doc.Building Permit Revised 2008mi !Vftor %Hot�p, ,,,!n so Built for a lifetime of relamden 0 0 John Flanagan Sales C017SUltal7t 373 Shattuck Way Ne-Aington, NH 03801 (603) 431-7800 www.custompoolsxom (800) 323-9509 jflanagn@yahoo.com Cell (603) 817-5082 3007 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATIOR M This certifies that ef� t .................... has permission for gas installation ... ............ in the buildings of x91'.'. ................ at North Andover, Mass. Lic. ..... .......................... GASINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PER I , TO DO GASFITTING (Print or Type) NORTH ANDOVER , Mass. Date 10/23 1998 Permit # 300 Building Location 1520 FOREST STREET EXT Owner's Name PHIL MORGAN NORTH ANDOVER, MA 01845 Type of Occupancy SINGLE New Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No [ Installing Company Name TOWNSEND OIL COMPANY INC. Address .75 WEST MAIN STREET GEORGETOWN, MA 01833 Business Telephone (97R) 359-8711 Name of Licensed Plumber or Gas Fitter KEN JACKSON L.P.1978 Check one: Certificate CX Corporation ❑ Partnership ❑ Firm/Co. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes KI No ❑ !:A,ou have checked yes, please Indicate the type coverage by checking the appropriate box. 'i-,�bil'rty insurance policy C?F Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the GqrLeral Laws. lay T of License: Plumber Signature of Licensed Plur or Gas Fitter Titlesfitter {/ Master License Number L.P.#978,` CitylTown Journeyman APOFOvED (O IC USE ONLYY 1# e', ONES ■ ME .. MEMEME EM SSIMME��in� AMEN MEMMENEMEMEEMIN MEN Now MEMO MENNEN NOME NE 0 0 Elm 0 MEN MENIONEEMEMEM ARE MENSIMEM Installing Company Name TOWNSEND OIL COMPANY INC. Address .75 WEST MAIN STREET GEORGETOWN, MA 01833 Business Telephone (97R) 359-8711 Name of Licensed Plumber or Gas Fitter KEN JACKSON L.P.1978 Check one: Certificate CX Corporation ❑ Partnership ❑ Firm/Co. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes KI No ❑ !:A,ou have checked yes, please Indicate the type coverage by checking the appropriate box. 'i-,�bil'rty insurance policy C?F Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the GqrLeral Laws. lay T of License: Plumber Signature of Licensed Plur or Gas Fitter Titlesfitter {/ Master License Number L.P.#978,` CitylTown Journeyman APOFOvED (O IC USE ONLYY 1# e', / - "'/ - -'7 6c, & 3523 Date ..................... v�ORTN TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION -- iA1111ft X This certifies that ........................... has permission for gas installation .............. in the buildings of . . ./� -7?� �� ....................... e- ) /— 5- / . Z --,q 7— rth Andover, Mass. at.......... 17 7; Fee. Lie. No ........... GASINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 20 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) NORTH ANDOVER Mass. Date 12/3119 99 Pcrmit # d�3 Building Location 1 920 FnRF.ST 9T FXT _ Owner's Name NORTH ANDOVER, MA Type of cupancy SINGLE New ❑ Renovation ❑ Replacement ❑ 1 Plans Submitted: Yes❑ No ❑ _.�!iiny Ccr .zany tiam,.e TOWNSEND OIL COMPANY ~:~dress 75 WEST MAIN STREET - GEOREGTOWN , NIA 01833 =usiness T.c.iep,ore 979-352-8711 ceraced :-P!:umnbt�r -r;;r •G -as Fn1cr Chcck cnc: Corporation Fartnership Firm/Co. KEN JACKSON Ce? moat^_ INSURANCE COVERAGE: I ~.ave a curren Q-bi!iy insurance pc icy or s substantia! meets the requirements cf f.!GL Ch. 1412. Yes No f ,Cu have C`eCkCC1�^s. P�Czse ,,,pc cc"vcrz'-C by check;ng','.c apprcpraie bo X. A liability insurance policy ? Other type of indemnity O bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance cover -ace required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: owner' Agent ❑ Ssnzture of C�•'ner or C--ner s Anent I hereby certify that a4 cf the details and information I have submitted (or entered) in above application are true and accurzte to the :est cf, rm' kr,,cw4edce and t~z; 2!1 plumbing work and ins!al!zlions performed under the p mil issued for t`.is application h^II be in CC—';p iznc* v ,:h z:l pe :iner.t provisions of the N.tssac;huse's state Gas Code and Chapter 112 of the General taws. f ey T of license: Plumber y nalure of Ucensef Purnt>er .or Gas Filter Master ticen;e Nurnber L t Uty/Town Journeyman 4 ( I U c NL r N G N W N Y Z G vi N N U C } G Vf G O V1 y H W w G O U ❑ F' _ s� (,, V J W O O 13 �. cJ W J W O O W �� W Z U W G w C W ~ W ~ V1 C < W 7 C W < C < < O OC W G O ~ Z O V LL r O 3 o J J U C >Uj I S:JB—BSMT. -ASE).- u.215TFLOOR + IST FLOOR I + 1 214D FLOOR I I l I I I I I I I 3RD FLOOR I I I 1 sTHFLOOR I I 1 I 5TH FLOOR 6THFLOOR J 7TH FLOOR 3TH FLOOR _.�!iiny Ccr .zany tiam,.e TOWNSEND OIL COMPANY ~:~dress 75 WEST MAIN STREET - GEOREGTOWN , NIA 01833 =usiness T.c.iep,ore 979-352-8711 ceraced :-P!:umnbt�r -r;;r •G -as Fn1cr Chcck cnc: Corporation Fartnership Firm/Co. KEN JACKSON Ce? moat^_ INSURANCE COVERAGE: I ~.ave a curren Q-bi!iy insurance pc icy or s substantia! meets the requirements cf f.!GL Ch. 1412. Yes No f ,Cu have C`eCkCC1�^s. P�Czse ,,,pc cc"vcrz'-C by check;ng','.c apprcpraie bo X. A liability insurance policy ? Other type of indemnity O bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance cover -ace required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: owner' Agent ❑ Ssnzture of C�•'ner or C--ner s Anent I hereby certify that a4 cf the details and information I have submitted (or entered) in above application are true and accurzte to the :est cf, rm' kr,,cw4edce and t~z; 2!1 plumbing work and ins!al!zlions performed under the p mil issued for t`.is application h^II be in CC—';p iznc* v ,:h z:l pe :iner.t provisions of the N.tssac;huse's state Gas Code and Chapter 112 of the General taws. f ey T of license: Plumber y nalure of Ucensef Purnt>er .or Gas Filter Master ticen;e Nurnber L t Uty/Town Journeyman 4 ( I U c NL r CONTRACT# CIVto.POOL SIZE kA -X Ass CONTRACT DATE \O DEPTH %1-1 _X -!g IX_ SALESMAN Qkga�� OO if Inc. CODE -SHAPE �(Zk2S& As Z RES.%_COMM. SWIMMING POOL CONTRACTOR SPA ATT. SEP INDOOR -OUTDOOR_ 373 Shattuck Way SPA DIAM XDEPTH Newington, NH 03601 3V- SC Ph: 603-431-7800 Fax: 603-431-5109 WWW.CUSTOMPOOLS.COM THE GENERAL TERMS AND CONDITIONS ON THE REVERSE SIDE ARE PART OF THIS AGREEMENT 3TS' IQh4 DC7 THIS CONTRACT MADE AS OF THIS DATE OF ACCEPTANCE BY "CONTRACTOR" PHONECq`15s- AND, NAME p. jnc ¢ "-�Nde t% HEREIN TERMED "OWNER" PHONE PHONEQtk-51ei- MAIL ADDRESS \<a< �5j a \edea 1 A&kS CITY, STATE, ZIP i-SAMM, SITE ADDRESS \,`Sa grnQT ` h • ems• CONTRACTOR a iN.Clcsavr Mctia1 GENERAL SERVICES by CONTRACTOR EQUIPMENT/PLUMBING/ELECTRICAL-POOL 1. Standard structural engineering plans and specifications. 1. Cleaning system: type �'' Y�'O � A -<yes_❑ no 2. State construction permits if required. 2. Filter(s) 1� �..� C oil\ 7 q� Wyes--- ❑ no 3. Hand forming and shaping of pool and/or spa. 3. Skimmer(s) !Tftq- Crk\ ,Ryes --o no 4. Excavate pool and remove dirt on day of excavation. 4. Pump(s) IT'66_fl[2aZIC \ Y�;n .'res_❑ no 5. Install non -corrosive PVC plumbing throughout pool. 6. Install main drain with hydrostatic relief valve. 5. Heater(s) V aAtps_❑ no 7. Set filtration equipment per contract and connect to pool plumbing. EQUIPMENT TO BE INSTALLED WITHIN FT OF POOL 6. Chemical Feeder(s) ,bp(es_❑ no 8. Install steel reinforcing throughout structure. 7. Ozone ❑ yeS_�?lo 9. Install gunite shell to meet or exceed city/county/state code. 8. Other ❑ yes---Pioio 10. Pressure test all plumbing and equipment. 11. Start up pool, provide instruction, manuals and start-up kit. GRADING AROUND POOL FOR DECK 12. Cleanup construction debris. 13. Pay state and federal taxes per law. 14. Provide public liability and workman's compensation insurance. Because all pool sites are different in the amount of time and the amount of fill 15. Provide property damage insurance during construction. required, we cannot give you a fixed cost for this work at time of contract signing. Custom Pools, Inc. charges $125.00 per hour (4 hours minimum) for spreading fill OWNER'S RESPONSIBILITIES and grading. The cost of fill is to be paid by the owner nme of delivery or Custom Pools will bill owner for fill at cost + 20% (owner initial) ��YY 1. To provide local permits for pool construction. 2. Provide access to pool location for construction equipment. DECK EQUIPMENT TO BE INSTALLED BY: 3. Provide water and power for construction. DECK ANCHORS TO BE INSTALLED BY: 4. Approve pool elevation and verify location of property lines. 1. Ladders ❑ yes 0 5. Pay for any additional costs incurred due to underground obstacles, Grabrails at recessed steps ❑ yes_Xno rock or water, etc. Hand rails ❑yeSoO Diving board''Qft. ❑ yes ono 6. Pay for any additional costs due to soil with inadequate bearing 2. Handicap lift ❑yeS--Ao Anchor ❑ yes_Wo capacity. 7. Electrical, gas and domestic water hook-ups, and heater venting if EOU IPMENT/PLUMBING/ELECTRICAL - SPA needed. I. Size/perimeter Dam we Ength ft. ❑ yes ---Q no 8. Water curing of gunite shell for at least 7 days. 9. Provide water for filling of pool immediately after plastering and to 2. Sharing pool equipment ❑ yes ---o no brush new plaster surface for two weeks as instructed. 3. Separate spa with own equip men ❑ yes ----o no 10. Provide construction or permanent fencing per local%�t,�y,1e. Specify equip. extra pump(s) ❑ yes ---Q no I1. Maintain pool after completion. �iLiiwner initial) ��4/l✓l Skimmer(s)oyes --Qno Heater _ ❑ yes_❑ no 4. Light under bench ❑yes_❑ no GENERAL CONSTRUCTION SPECIFICATIONS 5. If raised spa specif ❑ yes_❑ no 6. Main drains ❑ yes --o no ❑ no 1 Normal excavation with standard equipment ❑' yes no `_ Special equipment needed for excavation�� " 7. yes ---o Dirt to be removed ❑ within 1 mile ❑ left on site? ❑ other? MISCELLANEOUS l ANEOUS EOUIPMENTlEXTRAS 2. Specify any items such as tree stumps, concrete, old pool or decking 1. Winter cover--Mz ❑ yes-X�o to be removed at time of excavation or any pregrading required. 2. Solar cover ❑ yes_ *Qo Additional cost to be added to contract. O.rL,- 3. Fall closing ><j(e5_❑ no 4. Maintenance kit to include wall brush, leaf skimmer, test kit, 3. Swimout/loveseatfeet j<yes_❑ no 4. Recessed steps in deep end ❑ yes_to thermometer �es_❑ no 5. Grand stair entry �_u of steps ' 11 �11k- )Qes_❑ no 5. Rope, floats, hooks ❑ yes�io 6. Perimeter edge tilever coping other ❑yes_❑ no 6. ❑yes_❑ no 7. {� ?M d~ �� - qes_❑ no 7. Standard 6" the rine. CPI color �- (yes_❑ no � GYMyy� e� \ no 8. Depth markers on perimeter tile _on deck yes ---o _ 9. Accent tile ❑ yesboo 9' �e�� Su � � ❑yes_❑ no 10. Other the ❑ yes_ QW0 10.❑ yes_❑ no 11. Raised beam leng It ❑ yeS__A.f10 11. ❑ yes_❑ no 12. Underwater safety light(s)� \\ eL)br >4yes_❑ no 12' ❑ yes ---o no 13. Fibetoptic light(s) ❑ yes_Ano 13. ❑ yes ---D no 14. Perimeter lighting ❑ yes- Cno 14. ❑ yes --o no 15. Interior finis plaster other dyes_ono 15. ❑ yes_❑ no ADDITIONAL SPECIFICATIONS: Pool to be started upon issuance of required permits and shall be finished PAYMENT SCHEDULE - Contract amount within workable days, excluding Weekends and Holidays and to be Down payment subject to all provisions of this Contract. Balance due Sd \ ACCEPTED this day of O 2010 50% due after Excavation and Steel 45% due after Gunite Application 5% due prior to Interior Finish by: Title: Custom Poo 'o by: ��it This is not an estimate - The general terms and condition on the reverse side Pool owner or in iridual responsible for pa ment of contract. / are part of this agreement. KS v oooo OD N N C O C6 ~ O OL 0 OO N co (B co ` �-1 O C .0 4 M is CCi O v� a cn � Pio•, `�' O ' N bA oj. U a� � Cl bp o 0 o � O F•-�•i V >- ao U <O co C p UZ O=Z) Q-Lf—�O Q O1 O�=� U) CO 3: :3 ti U CO co Z a � U y ElU Ira y N a d' 0 co N o ? U c L 2- Q o O U 0 - U m �R Z CD N .� N �D W N Lu a. a� o a0 > cai O c,cl.:ci o:o,,:a cc o LU V) •a ,, > I' coo o p w U 2 0 o 0 D Z a o~ L Q O U y c U m n Z z N / \ I I aN / JLLI w o moz/ 13w / co / o o / \ o) i P0l, PMR Cb `� o \`\ / co 7 / I 1 �► � / � O 10� ` Q <V Y6 - I Ip I \ � o i � •� � ~ I I = ICLO pF6 rJ6 I — , LOG Md ° � 1 LO \ O i \ � � O\ \� I \ d� ice/ \ ° ✓ :,,,7 �N O. ti O O 1f') 1 \Co. ,SRP--_-- ? Q k0 i V — 0 — t. l _ 300 moo 00 O —_ ' S 00 6\ LA- 00 000 O^' 00 V 0 0 \ \ 1►//// \ \ I i ID�iS� c I -�1< J i iu� C% CL J s I CJ 0WD L cio S 0::2- F - � � iiJ O W U C). 14- > N OOU 0 W z .< C) t'� QO¢ .-� U C? :r — Z M m m V�cn �w a •5 U.3U > xU z (n Q W ZQ�O O u Ln W Wd'= o vi (J)0 O i L -: O U N W l o II W^ UM.. C -D a- hum LO Q r m WJ o X0`3 Q U C3 CO o� Q a• aQ�m- zg Aj 4 Qj 0 QW � o0o i z .AZ CZ m a ao �z� I vVi WR ZZ K e WSW �� 'K -K -K�u �y nkN 'Ke The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 �. z• www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/FlectriciansfPllumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 6M1_1 rr.`� 7. re�-C� Address: 5N,��,c C.yc.A City/State/Zip: 1�.N`�' \ sS�\ Phone #:� Are you an employer? Check the appropriate box: 1.1� i am a employer with 5D 4. ❑ I am a general contractor and I employees (full and/or part-time).' have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling . 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. E] Plumbing repairs or additions 12.0 Roof repairs 13 ]Other 7Sw_%aco,,, �, *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 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 and 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: .... ri�,e .. �. r, .. ca G0 • G e � .� Policy # or Self -ins. Lic. #: UX_' Expiration Date: L�-L-S,Zn11 Job Site Address: K.`S�k.5 City/State/Zip: x �' Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure 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 ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do Hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct. Phone #:-2 3'\- 'rL� 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 0 THE COMMONWEALTH OF MASSACHUSETTS Department of Public Safety One Ashburton Place, Room 0 1301 L Boston, MA 02108-1618 ,CJ N •� O ✓. C N r a : RENEWAL OF CONSTRUCTION SUPERVISOR LICENSE 0 c ` o a v H x E _ ` W Gl w o a in Q SCE .`o_ . :w o )3820 o Z Please note changes to mailing address. t C c V o W Z c f Z F7 Last Name: SHORT z ix m J w � 3 " First: EUGENE N o City: DOVER POINT Licenses not renewed by the expiration date shall become void, and shall after one year be reinstated only by re- O rA O as o w° ; a U) 0 o o w° 0 ° r o U G ii. 0 C o w°' � w a E� a W m o w°' u cn w a ora o a°' w A �, � N rA o z cn Q o cn ui 0 z p_ C C�7 O � N O 4 v v C7 CL gm CD cc E a Cl) COCEL COD = w �. o- VJ E s CJS �r l jCCD � � U IS, cm Lou a U �� 0 3 cn y W O Co.ria y � w U E . O 0 cmA-r :y�' m c Cl) .. =oa W Z3 y�.•cc= m 6 v42 o INC �•CZ o U C C O d m C=2 O C •C H a0+ H O CO W CO •t O C Z a z m •y C C. •m v ®� C=M H y M. O� O = R i y•7 C - CL m _ Ico cm O O 'D .� ym .ff m co CD 43 0 0 � C.3 0 o a a ora CO2 C c ev cc v J .O c O Z C3 C CL V y C O C C lift cc CL H 0 � LU U) W W 19 W U) a' CONTRACT # t to POOL SIZE kX AS -X CONTRACT DATE 1l1 \-O DEPTH %V X�X SALESMAN OO ♦ Inc. CODE SHAPE (�eC�smy RES._)<.-COMM. SWIMMING POOL CONTRACTOR SPA ATT. SEP INDOOR' OUTDOOR373 Shattuck Way SPA DIAM XDEPTH Newington, NH 03801 3CV_ SV Ph: 603-431-7800 Fax: 603-431-5109 WWW.CUSTOMPOOLS.COM THE GENERAL TERMS AND CONDITIONS ON THE REVERSE SIDE ARE PART OF THIS AGREEMENT THIS CONTRACT MADE AS OF THIS DATE OF ACCEPTANCE BY "CONTRACTOR" PHONEq vu5- 3'IS-145k4 (C� AND, NAME HEREIN TERMED "OWNER" PHONE MAIL ADDRESS 53c.-.Qc\per \ PHONEg1iS-!;6k- CITY, STATE, ZIP tt� SITE ADDRESS Qy^eQ-T Sb, &,ft. CONTRACTOR Ate �c�oar Mct,1 GENERAL SERVICES by CONTRACTOR EEQUIPMENT/PLUMBING/ELECTRICAL-POOL 1. Standard structural engineering plans and specifications. 1. Cleaning system: type V. -'yes_❑ no 2. State construction permits if required. 2. Filter(s) F%hu Q! .'Ar !&-I -&A, v).Z. Ntes_❑ no 3. Hand forming and shaping of pool and/or spa. 3. Skimmer(s) !2�41;'u� ,Xyes_❑ no 4. Excavate pool and remove dirt on day of excavation. 4. Pump(s) `l1 ,res_❑ no 5. Install non -corrosive PVC plumbing throughout pool. 6. Install main drain with hydrostatic relief valve. 5. Heater(s) kej&x ci`J iKLes_o no 7. Set filtration equipment per contract and connect to pool plumbing. EQUIPMENT TO BE INSTALLED WITHIN _ FT OF POOL6. Chemical Feeder(s) $yes_❑ no 8. Install steel reinforcing throughout structure. 7. Ozone ❑ yes�4io 9. Install gunite shell in meet or exceed city/county/state code. 8. Other o yes�10 10. Pressure test all plumbing and equipment. 11. Start up pool, provide instruction, manuals and scan -up kit. GRADING AROUND POOL FOR DECK 12. Cleanup construction debris. 13. Pay state and federal taxes per law. 14. Provide public liability and workman's compensation insurance. Because all pool sites are different in the amount of time and the amount of fill 15. Provide property damage insurance during construction. required, we cannot give you a fixed cost for this work at time of contract signing. Custom Pools, Inc. charges $125.00 per hour (4 hours minimum) for spreading fill OWNER'S RESPONSIBILITIES and grading. The cost of fill is to be paid by thee of delivery or L To provide local permits for pool construction. Custom Pools. will bill owner for fill at cost + 20% (owner initial) 2. Provide access to pool location for construction equipment. DECK EQUIPMENT TO BE INSTALLED BY: 3. Provide water and power for construction. DECK ANCHORS TO BE INSTALLED BY: 4. Approve pool elevation and verify location of property lines. 1. Ladders ❑ yes O 5. Pay for any additional costs incurred due to underground obstacles, Grabrails at recessed steps ❑yes_ 14no rock or water, etc Hand rails oyes p0 Diving board - 6. ❑ yes --o n0 6. aapyacitany additional costs due to soil with inadequate bearing 2. Handicap lift oyes --A0 Anchor ❑ yes_wo 7. Electrical, gas and domestic water htok-ups, and heater venting if needed. EQUIPMENT/PLUMBING/ELECTRICAL - SPA 8. Water curing of gunite shell for at least 7 days. 1. Size/perimeter Dam wall Ctngth ft. ❑ yes_❑ no 9. Provide water for filling of pool immediately after plastering and to 2. Sharing pool equipment ❑ yes ---o no brush new plaster surface for two weeks as instructed. 3. Separate spa with own equipmen o yes --- ono 10. Provide construction or permanent fencing per local ride. Specify equip. • extra pump(s) o yes _❑ no 11. Maintain pool after completion. owner initial) Skimmer(s) ayes -ono Heater _ o yes - no 4. Light under bench ❑ yes_❑ no GENERAL CONSTRUCTION SPECIFICATIONS 5. If raised spa specif o yes --o no I Normal excavation with standard equipment o yes + no 6. Main drains o yes --o no Special equipment needed for excavationm� 7. ❑ yes_o no Dirt to be removed ❑ within 1 mile ❑ left on site? o other? MISCELLANEOUS EOUIPMENTIEXTRAS 2. Specify any items such as tree stumps, concrete, old pool or decking 1. Winter cover-lan ❑yes O to he removed at time of excavation or any pregrading required. Additional cost to be added to contract. 1C--`�or.+tL2. Solar cover ❑ yes-_3CLio 3. Fall closing ><Xes_❑ no 3. Swimout/loveseat SLfeet *es_o no 4. Maintenance kit to include wall brush, leaf skimmer, test kit, 4. Recessed steps in deep end (3 yes--;Koo thermometer >&es_o no 5. Grand stair enc _-3i,_#of steps es_o no 5. Rope, floats, hooks o yes_'N:�o 6. Perimeter edge tilever coping ocher ❑ yes_ono 7 � �� ❑ yes_o no 7. Standard 6" the rine. CPI color �- �yyes_o no 8 Q3Q54 ,;sQes_❑ no A� 8. Depth markers on perimeter tile _on deck o yes-_woy )*m , i o yes ---o no 9. Accent tile o yes_Pwo 9. Nela?.k ❑ Yes_o no 10. Other the o yes ---.*({to 10. o yes_❑ no 11. Raised beam length heigh o yes -_Ano 11' oyes -o no 12. Underwater safety light(s)-_4Z4,� C��c.t Xyes_❑ no 12. ❑ yes_o no 13. Fiberoptic light(s) ❑ yes_Ono 13. ❑ yes --o no 14. Perimeter lighting ❑ yes_itno I . o yes_o no 15. Interior finis plaster other. Kyes_o no 15. o yes - ADDITIONAL SPECIFICATIONS: tai Pool to be started upon issuance of required permits and shall be finished PAYMENT SCHEDULE - Contract amount within _ workable days, excluding Weekends and Holidays and to be Down payment \� . C)C?ZJ ✓ subject to all provisions of this Contract. Balance due a\ ACCEPTED this day of20b 50% due after Excavation and Steel _ 45% due after Gunite Application 5% due prior to Interior Finish by Title: Custom poo1y�/1�o by L -yq This is not an estimate - The general terms and condition on the reverse side Pool owner or in witlual responsible for Pa4mem of �omrect. are part of this agreement. /� y,S \wc `fit ` ` •`J�p(