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HomeMy WebLinkAboutBuilding Permit #152-2016 - 242 DALE STREET 8/4/2015 BUILDING PERMIT Na pTH qti 4-6 UP TOWN OF NORTH ANDOVER �� ._'n_.6 O APPLICATION FOR PLAN EXAMINATION Permit No#: 1` Date Received Date Issued: I� gss'iCH►1s�� I IMPORTANT: Applicant must complete all items on this page LOCATION oo� Q SQPN. nc� ��� fY1� 5 Print PROPERTY OWNER JLO 1',e— N�Af U Print 100 Year Structure yes no MAP _PARCEL:P b ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ DemolitionOther ❑ Septic ElWell ❑ Floodplain El Wetlands [I Watershed District ElWater/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name:s N!ko m Phone: (Q Address: c) D 01b+6 Dee ve A'If"as Kms_ Contractor Name:,#///',-.f to &sem ecls Phone: �G 3 - �I f� Email: Address: / 7 G!J oK l�vac� �r 7eG� y�f Q csolQ�3c� 7 ! �' c�l7 Supervisor's Construction License: `; Exp. Date: r Home Improvement License: Exp. Date: 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: $ lo. - FEE: $ 23 ' Check No.: Receipt No.: NOTE: Persons contracting with unregistered ontractors do not have access to the guaranty fund 1 Location 2-41 No. '4'-3,D — 2-0, Date X1`0115 . - TOWN OF NORTH ANDOVER rT.ED 7646 • Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check 4t-3 0 U I l.� 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 ❑ I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On 3 7 Signature ,�Jzw�.� COMMENTS lw2Ls— CONSERVATION Reviewed on Si nature COMMENTS HEALTH Reviewed on ( Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes r Planning Board Decision: Comments r� Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE)DEPARFMENT - TempDumpster onsite ,yes- Ino �.a .�.. locatedlat 124�Main�Stceet: Fire,Department!0 nature/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 Call Email Date Time Contact Name ---__...----...--------� -—---- Doc.Building Permit Revised 2014 i 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 - sjeNz-� Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products IS 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) 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 LEGEND: LAWN CARE OR MAINTENANCE. WETLAND DELINEATION BY ARROW SITE ENVIRONMENTAL SERVICES ON ----248--- TWO FOOT CONTOUR THE ONLY FERTILIZERS ALLOWED FOR USE ON THIS PROPERTY APRIL 25, 2015 GLENMOE 92X00 SPOT GRADE SHALL BE ORGANIC OR SLOW-RELEASE NITROGEN, PHOSPHORUS AL CIRCLE FREE PRODUCT. DECIDUOUS TREE NON-ORGANIC PESTICIDES AND HERBICIDES USE IS PROHIBITED. Al Bvw AZ A3 THESE STATEMENTS SHALL ALSO APPEAR AS A DEED I B DALE SIR Bt T. BITUMINOUS 94------- Ir A4 3/6 0 18" EEI RESTRICTION TO RUN WITH THE TITLE. -- 10 YR 29A� WETLAND FLAG 26.6' -_- TEMPORARY BENCHMARK CHART: 94 m 11L WETLAND RESOURCE AREA 25 BVW BUFFER 95x•1 18" 14" 94x77 1 UPM, UTILITY POLE TBM # DESCR/P TION EL V. NO DISNRBgNCE" gg_ -� PROP. 4'HIGH BLACKCOATED 1, a _/ 95 CHAIN LINK FENCE ALONG �-(100)-� PROP. CONTOUR 0 STAKE& NAIL IN LAWN 100.00' * PROP. EROSION) �� ------ 00' REAR PROPERTY LINECONTN (SEE DETAIL) s8 68.6• EX TREE TO BE REMOVED 97,00 I �22" \\ ^ * ASSUMED DATUM 97x59 LOT AREA - 50'BVW BUFFER ` - 16,200 S.F.t 96X15 -"PROP. 4'HIGH (TBR) TO BE REMOVED NO STRUCTURE" 100 � ALUMINIUM FENCE CON/EER TREE \ ' �Oi-GREAT-MARCH 22, 1973 xtTf8�9' PROP. STAKED SILT FENCE LOCUS MAP: �_ ALONG BACK HALF OF SOIL NOT TO SCALE " Ex. Grassed Area �.- STOCKPILE AREA _ NOTES. BVW BORDER/NG VEGETATED WETLAND ALU IUM HFENICE --- / I'ROp\ 50'BVW BUFFER 102- i 1 -- - O+n�O,/,LN0 STRUCTURE" _ x58 24"P ^'^W(�c 101x19 R�1-� PROP. EROSION 1. THE TOPOGRAPHY, SITE DETAIL & SURFACE IMPROVEMENTS DEPICTED 4 -- CONTROL(TYP) HEREON WERE OBTAINED FROM A PARTIAL FIELD SURVEY CONDUCTED ON 8•• (SEE DETAIL) MAY 4, 2015 BY SULLIVAN ENGINEERING GROUP, LLC. APPROXIMATE LIMIT OF 29.6" -- PDP AB04Ep2DUND POOL 00 100r \ NHESP P PROP. POOL MECHANICALS RIORITY HABITAT ° (16'+327-� 207, _100 (NO BACKWASH SYSTEM) 2. THE LOCUS PROPERTY DEPICTED /S LOCATED IN ZONING DISTRICT R1 DEMARCATION " _ X04-_ o - FILTER CARTRIDGES FINISHED SLOPE NOT \ 103x84 0 C5b'm T_' APPROXIMATE LIMIT OF J. THE LOCUS PROPERTY/S DEPICTED AS LOT 30 ON THE 04 8 __ ® 00 0° 102, NHESP PRIORITY HABITAT TOWN OF NORTH ANDOVER ASSESSOR'S MAP 64. TO EXCEED 3:1 SLOPE � ' 10.60 xv 00'BVW BUFF 10 % - 0 apo A' R)nu0000 \ 20" DEMARCATION 3 0p' "NON-D/SER,g 6 28.8 ° po �-oir -102 4. THE LOCATION OF ALL UNDERGROUND UTILITIES SHOWN ARE APPROXIMATE R DOES NOT WARRANTY NOR 1 \/\ ONE IN -DIST RBANCE" - j 00a. ° 1 Prop. Ret. Wall (2.33'High) AND ARE BASED UPON A PARTIAL FIELD SURVEY AND COMPILATION OF �0 Bottom ofof IWall = 101.00' GUARANTEE THEPLANS OF LOCAT70N OCA 0NEOF ALLSIGN UTILITIESES DEPICTED OR NOT DEPICTED. ` o -� THE CONTRACTOR, PRIOR TO COMMENCEMENT OF CONSTRUCTION, SHALL m a°o o 100 BVW BU VERIFY THE LOCAT70N OF ALL UTILITIES AND CONTACT DIG SAFE AT \�\ 000 Baseme .� '104 100' BUFFER& 4'MAX. !07 9 ° Elevationt=p5221 ZONE IN Wq is TU BANCE" 1-888-344-7233. 12 INCHES OF FREE i_0 Note: Pool Chemicals ED 5. THIS PLAN DOES NOT SHOW ANY UNRECORDED OR UNWRITTEN EASEMENTS DRAINING AGGREGATE 08_ -_ .08x36 t0 be stored in WHICH MAY EXIST A REASONABLE AND DILIGENT ATTEMPT HAS BEEN MADE PROP. 3/4'CRUSHED STONE 278• ° asement area EX. BLOCK PATIO TO BE TO OBSERVE ANY APPARENT, VISIBLE USES OF THE LAND; HOWEVER, THIS TO BE PLACED UNDER SIDE ° --106 REPLACED IN-KIND 4" DIA. DRAIN TILE (EL. VARIES) DECK AND POOL DECKING / DOES NOT CONSTITUTE A GUARANTEE THAT NO SUCH EASEMENTS EXIST. TO A DEPTH OF 6'EHATCHED TO PROMOTE O 0, 9 EXISTING 1 STORY x 6. THE ELEVATIONS DEPICTED HEREON WERE BASED UPON AN ASSUMED DATUM. I _ _ _ _ _ RECHARGE. 3 WOOD FRAME STRUCTURE If/ PROP. 6'HIGH PVC FENCE First Floor DRAINAGE MITIGATION: Elev_112.50' NOTE. RETAINING WALL TO 6" MINIMUM COMPACTED 1l0 ,� -� 8242 a -108 OWNER IS PROPOSING TO MITIGATE THE IMPACT OF THE IMPERVIOUS TAX MAP 64 PARCEL 79 7 ABOVEGROUND POOL FOOTPRINT (457 S.F.) BY INSTALLING CRUSHED CONSIST OF VERSA-LOCK 2' TYP GRANULAR BASE I CAR 91 STONE 6" DEPTH) BELOW THE DECKING AREAS (TOTAL OF 688 S.F.) STYLE BLOCKS LEVELING PAD #240 DALE STREET 110X81 GARAGE TAX MAP 64 PARCEL 27 N/F KELLY DUNCAN #244 DALE STREET HATCHED IN THE SITE PLAN TO PROMOTE GROUNDWATER RECHARGE. 112 Veh/d�/sfZcfio =I760611V F N/F 244 DALE STREET REALTY TRUST SITE GRADING: RETAINING WALL DETAIL °x48 ��ace s I - „D Ex. Landsc THE ONLY SITE GRADING CHANGES ASSOCIATED WITH THIS PROJECT (NOT TO SCALE) Ret. Wall( 2tl Ston ARE IN THE AREA OF THE PROPOSED ABOVEGROUND POOL (TO LEVEL 114 x. F/9h Ex. Bit. THE AREA FOR INSTALLATION OF THE POOL AND IN THE AREA OF THE Conc. PROPOSED RETAINING WALL BENEATH THE DECKING. D ur 1px riveway ■— \\E 113x71 to _ \ POOL MAINTENANCE.• AMOCO, 1380 SILT — — HAYBALES 116 (^� �I \`I� -- -- _112 i) POOL CHEMICALS TO BE STORED IN BASEMENT AREA. STOP (OR EQUAL) _ «✓24" ` y, a 2) NO BACKWASHING OF POOL REQUIRED. OWNER TO UTILIZE _■_ / �' NOF / FILTER CARTRIDGE SYSTEM. _■ STAKE FLOW `� R=665.00 �\_ 4 CML y RECORD OWNER: L=70.00' No.4tM ASSESSOR'S MAP 64 PARCEL 30 JULIE NIGRO WOOD POST `S10NALE'\ 242 DALE STREET _.■—�_ HAYBALES NORTH ANDOVER, MA 01845 (BUTT TOGETHER) DALE STREET - DEED 600K 12615 PAGE 5 „O #242 DALE STREET PM SITE DEVELOPMENT PL" OF LAND PLAN VIEW ZONING TABLE: r D I WOOD STAKES #Ny15 7.7' O.C. ZONING DISTRICT R1 NORTH ANDOVER, MASSACHUSETTS AMOCO, 1380 SILT 1"X 1"X 3' STAKES W/IN WATERSHED PROTECTION DISTRICT ESSEX COUNTY STOP (OR EQUAL), (2) PER BALE 3.5' WIDE REQUIRED PREPARED FOR HAYBALES TO BE ENTRENCHED MIN. 3" MAX. HEIGHT 35 FEET JULIE NIGRO FLOW MIN. FRONT SETBACK 30 FT GRAPHIC SCALE SCALE: >"= 20' DATE: MAY 6, 2015 SCALE.1"=20' 6"X 6" TRENCH MIN. SIDE SETBACK (L) 30 FT FEET PREPARED BY WITH BACKFILL V 20 0 10 20 40 80 IN PLACE MIN. SIDE SETBACK (R) 30 FT SULLIVAN ENGINEERING GROUP, LLC CROSS SECTION MIN. REAR SETBACK 30 FT REVISIONS P.O. BOX 2004 YYOBURN, MA 01888 MIN. LOT FRONTAGE 175 FT (781) 854-8644 EROS/ON CONTROL BARRIER 1 6/9/15 REVISE DECKING JDS JOS(NOT TO SCALE) MIN. LOT AREA 87,120 S.F. NO. DATE DESCRIPTION BY CHK'D SHEET No. 1 OF 1 ooRTH own o E ndover 0 - :: No. - h ver, Mass,A, cocN�cNew�cK �1' X1,9 A4, o �P�`,��(5 S U - BOARD OF HEALTH Food/Kitchen PER .MIT T LD Septic System THIS CERTIFIES THAT10.. �.... ,,,,,,,, ,,, ,,,,,,,,,,,,,,, ,,, , BUILDING INSPECTOR . . ..... ....... .. .... Foundation has permission to erect _ . .. ................ buildings on'; n .......�... ....C....514............................... Rough to be occupied as ........... ... .....�. ►w. Pv�I �. . ...................... Chimney . ......... .... ............... provided that the person accepting this a shall in eve res ect conform to the terms of the application p p p g p rY p 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 CONSTRUCTION RTS Rough Service ................. :.... ............ ... ::�:.�:..................... Final BUILDING 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. Family Pools North Account# A13052 3 Newton Jct. Road Unit 4 Estimate# S11667 Kingston, NH 03848 Date 6/22/2015 Tel:(603)642-9909 Estimate Amt $10,284.04 Planned Start 8/3/2015 Planned Completion 8/7/2015 Rob Barter 242 Dale St N Andover, MA 01845 Amount Remitted Estimate Date 6/22/2015 Estimate# S11667 Description Pool Purchase and Installation.7'Deep End. NOTE: Excavator charge is estimated. Finall charge will be based on actual Item# Qty. Unit Price Tax Total 1 1.00 Each $1,750.00 $0.00 $1,750.00 Installation-16x32 Pool 2 1.00 Each $6,800.00 $0.00 $6,800.00 Palm Shore 16'x32'Platinum Pool Kit includes: 1-1.25"x 40'Vac Hose,AG,2-1.5"Hayward Trimline Ball Vlv MIPxFIP,1-16X32 Solar Cover,8 mil,1-4x15'Air Pillow,0.08-8'Anodized Telescopic Pole Case,1-Armor Shield Floor Pad, 16x32 Oval,1-Calcium Chloride,50 LB Bag,0.02-DE Scoop-CASE,1-Energizer Plus Shock, 1 LB-12 Pack,1-Ladder,A-Frame,Evolution,0.08-Lamotte 5 Way Test Strips,0.08-Leaf Skimmer Head MBP Case,0.13-pH Builder,5 LB Case,0.17-Premium Vinyl Liner Vacuum Case,1-Pristine Blue Mini Test Kit,0.08-Pristine Blue Qt. Case,0.08-Pristine Check Qt.Case,0.04-Pristine Clean Spa,8 OZ Case,0.13-Reducer 2000,6 LB Case,1-Return Winterizing Plug,w/0,0.5-Total Control 1000,25 LB Case,1-Ultra Vac Automatic Pool Vacuum,0.7-Wall Foam, 3 1.00 Each $265.00 $0.00 $265.00 16'x 32'Misty Falls 20 MIL Expandable Liner 4 1.00 Each $675.00 $.00(100.00%Off) $0.00 $0.00 PLD50,30 SF DE Filter w/1 HP-Included in Package Price 5 1.00 Each $135.96 $.00(100.00%Off) $0.00 $0.00 Ladder, Deck,Evolution-Included in Package Price 6 1.00 Each $150.00 $0.00 $150.00 Mid Size Excavator Mobilization Fee 7 5.00 Hours $150.00 $0.00 $750.00 Mid Size Excavator Hourly Rate. Dig time estimated based on dig in clean fill and for digging out 1 stump. Final billing will be based on actual dig time. 8 1.00 Case Of 2 $77.00 $0.00 $77.00 Main Drain,Hayward,Vinyl Family Pools North 3 Newton Jct.Road Unit 4 Kingston,NH 03848(603)642-9909(Phone)(603)642-9906(Fax) 71812015 5:51:46 PM Page 1 of 2 Page(s) 9 3.00 Each $2.96 $0.00 $8.88 1.5"Male Adapter MIPT x INS 10 3.00 Each $2.03 $0.00 $6.09 1.5"Female Adapter FPT x SKT 11 1.00 Each $8.45 $0.00 $8.45 1 1/2"Tee INS 12 40.00 PER/FT $1.08 $0.00 $43.20 1.5 Black Poly Pipe 13 1.00 Each $56.49 $0.00 $56.49 Jandy 1.5-2"3-Way Valve 14 1.00 Each $4.72 $0.00 $4.72 1.5"Elbow 90 INS 15 1.00 Each $14.21 $0.00 $14.21 1.5"Flush Union,SKTxMPT 16 1.00 Each $350.00 $0.00 $350.00 Main Drain Installation Totals $0.00 $10,284.04 Payment Scale Amount Due Deposit with Contract Sighning $3,599.41 Pool Delivered $3,599.41 Pool Complete $3,085.21 Installation includes:Level ground to within 6 inches of existing grade, patio block under uprights,errection of pool with stone dust and foam pad on floor,installation of liner,and set-up of pump and filter. Electrical installation,electrical permit and building permit not included in pricing. Water to fill the pool is extra. Excavation over 6 inches is extra if not specified herein. The removal of excavated material,and fill material needed are extra if not specified herein. Itis the responsibility of the owner to provide adequate access. Damages occurring to areas of access by normal means of construction are the responsibility of the owner. Water and electric to build with is to be provided by the owner. The owner is responsible to see that the pool is built within the established set backs established by the local legal authorities. Products supplied by this agreement are subject to the manufacturers' Warranties. Completion dates are subject to weather and conditions. Work not itemized is extra and will be charged time and material. Family Pools reserves the right to discontinue work if payments are not made as scheduled.A 2%finance charge after 30 days will be applied to accounts over due. When collections are needed, attorney fees and court costs are collectable. Prices quoted are good for 90-days. Signing constitutes acceptance with deposit due. FINAL PAYMENT WILL BE CASH OR CHECK ONLY Signature: Date: Signature: Date: Family Pools North 3 Newton Jct.Road Unit 4 Kingston,NH 03848(603)642-9909(Phone)(603)642-9906(Fax) 7/812015 5:51:46 PM Page 2 of 2 Page(s) The Commonwealth of Massachusetts Department of IndustrialAccidents f d 1 Congress Street,Suite 100 Boston,MA 02114-2017 y�,.•�t www mass gov1dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information /Please Print Legib a � ly Name(Business/Organization/Individual): /1#, 5 � 5?S,S& gwe;Gt7' L0191Trut/r/,dst L-G(-, Address: 1,97 A4 s°k 17,&V Aocq�--1 City/State/Zip: hone Are you an employer?Check the appropriate box: Type of project(required): 1.�I am.a.employer with _C : employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in $. [:1 Remodeling any capacity.[No workers'comp.insurance required.] ' 9. El Demolition 3.Q I am a homeowner doing all work myself,[No workers'comp.insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.# 6.Q pbo We are a corporation and its officers have exercised their right of per MGL c. 14 A Other / �Nt A a i0 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. i 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 state whether or not those entities have employees. If the sub-contractors have employees,they,must provide their workers'comp.policy number. d am an employer that is providing workers'compensation insurance for my employees.'.Below is the policy and job site information. / Insurance Company Name: LC O re — Policy#or Self-ins.Lia#: M I q_3 D 00 e2�! � Expiration Date: _5-46 Job Site Address: A.IV Y- au A_ St-, City/State/Zip:,✓.^4,14,de., �/� D/t o,- 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 thepains and penalties ofperjuiy that the information provided above is true and correct. Sign e: Date: Phone# 3- yfe '-a 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 enferprise,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-contractors)name(s),address(es)and-phoue number(s)along with their certificates)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 bum 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 ® DATE(MM/DD/YYYY) AC� �� CERTIFICATE OF LIABILITY INSURANCE 8/3/2015 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(ies) must be endorsed. If SUBROGATION IS WAIVED,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 CONTACT Victoria Lowes CISR NAME: MTM Insurance Associates PHC14. (978)681-5700 PJC No:(978)681-5777 1320 Osgood Street AIL ADDRESS:vickiel@mtminsure.com INSURERS AFFORDING COVERAGE NAIC# North Andover MA 01845 INSURER AAtlantic Casualty Ins Co INSURED -INSURER B:Preferred Mutual Ins Co 15024 Attics TO Basements Construction LLC INSURERC: 187 Wash Pond Road INSURER D: INSURER E: Hampstead NH 03841 INSURER F: COVERAGES CERTIFICATE NUMBER:15-16 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 TYPE OF INSURANCE ADDL UBR J=Jwa POLICY NUMBER MM/DO/LICY EFF POLICY EXP LIMITS X COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE $ A CLAIMS-MADE ❑X OCCUR DAMAGE TO RENTED 100,000 PREMISES Ea occurrence $ M143000293 5/6/2015 5/6/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑JECT PRO- F] LOC PRODUCTS-COMP/OPAGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 500,000 Ea.accident B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X AUTOS SCHEDULED AUTOS PCA0100709197 8/12/2015 8/12/2016 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE er X HIRED AUTOS X AUTOS Paccident $ Uninsured motorist combined $ 500,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) This certificate of insurance represents coverage currently in effect and may or may not be in compliance with any written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Family Pools North THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 3 Newton Juntion Road ACCORDANCE WITH THE POLICY PROVISIONS. Kingston, NH 03848 AUTHORIZED REPRESENTATIVE L Mancinelli, CIC/SAM yKe"U ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) Massachusetts-Department of Public Safety Board of Building Regulations and Standards �seiriSiuie`�uiJu»@>>iSue — License:CS-010330 GITI� WILLIAM C POURS / 70 S BROADWAY` S G� r LAWRENCE Alk Oi `J-�•.��� �.-wm Expiration Commissioner 07/19/2017