Loading...
HomeMy WebLinkAboutBuilding Permit #294-16 - 25 GREAT LAKE LANE 9/8/2015 BUILDING PERMIT NORT#y q ,~o TOWN OF NORTH ANDOVER °p APPLICATION FOR PLAN EXAMINATION r � o I Permit N0: Date Received 79�ONAre SSNCHUSE Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION Pnn# PROPERTY OWNER 7—k L � ° Print MAP NPARCEL': d ZONING DISTRICT: Historic District: yes` no 1Vl aachine Shop Village F ye rio 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: Demolition Other Septic, `Well Floodplain° Wetlands Watershed•District Water/Seger n . DESCRIPTION OF WORK TO BE PREFORMED: 2 X 3F3 /4&Z-00– a®C 7-0 &5- 5&.-1P' Identi&ation Please Type or Print Clearly) Z NOWNER: Name: t_I..L �Tt,� AkkoQ�i n Phone:q7 Address: 9&A' C.rt-�te-,5 CONTRACTOR Name: Ut �dMrr1� :,' PSS Phone.,. Address r3t = 1 , Supervisoe-s Coristruction License: Exp. ate,:-` 4 Home Ir pcovernent License. f exp, ;Date: ' :,?Ie?t� l00 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST 7BASED ON$125.00 PER S.F. Total Project Cost: $ S6,85-0 - FEE: $ Check No.: I o Receipt No.: NOTE: Persons contracting with unregistered c tractors do not have access to the guaranty fund 9 g.__� nature of.A ent/Owner =Signature of`contractor, vq n Location No. Lf Date e - TOWN OF NORTH ANDOVER Certificate of Occupancy .; Building/Frame Permit Fee $ Foundation Permit Fee $r Other Permit Fee $'t TOTAL $� Check .29 .3 Building Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL (�Publi:c� ewer \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 DATE APPROVED PLANNING & DEVELOPMENT COMMENTS 1) /S CONSERVATION Reviewed on / Si nature COMMENTS HEALTH a.; Reviewed/on Si S COMMENTS c Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes a 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 onsite yes .i Located�at124 Main Street Fire Department signature/date .. .ry COMMENTS' . . Dimension i 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) i ❑ Notified for pickup - Date I Doc.Building Permit Revised 2008 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 ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products j 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 NOTE: 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 a _ i Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 58,850.00 m $ - $ 706.20 Plumbing Fee $ 88.28 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 88.28 Total fees collected $ 982.75 OM 25 Great Lake Paine 294-16 on 9/4/15 Inground Pool Enter construction cost for fee cal - North Andover Fee Cakulation Construction Cost $ 583850.00 m $ - $ 706.20 Plumbing Fee $ 88.28 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 88.28 Total fees collected $ 982.75 25 Great Lake Lane 294-2016 on 9/8/2015 Inground Pool and Spa NORTH To' wn of T: A'. Andover 0 No. a9(of - h ver, Mass0 LA SA , cochIC"IWICK S BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ...........TIC.Z�o................................. ......... .............. BUILDING INSPECTOR � ...� � ... Foundation has permission to erect .......................... buildings on ...... . .... ...... .. .................+..:. Rough to be occupied as .... .. .......MEN.- ..... .. .oneu .. ..:.... ....� �...................................... Chimney provided that the person accepting this permit shalomevery respect conform to the terms of the application 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 NTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT Rough Service ................................................................................ Final i 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. J ALL SURFACE WATER SHALL PER STATE COMIC CODE DRAIN AWAY FROM POOL 3-M BARS IN BOND BEAM LKWNXHE T10P OF�BEAM IF 2 ELE1/10' . 34r MEd.WATER PROOF 3 MIN 6� MAX VERT. AL1. BEV 2'0' LEGE!F 4 RB FLASTER ENTRE POOL A�POIIrtT 1 NAii AL 03�0 w Otc BOTH WAYS ON C ,�SQNr LARD 1 +�R CUT OIC ALT BEV 3'0" MARS S'Ali'Ks�E OMAs DOTED ELEY S'0° MAfN DRAIN HVDlt05TA7>iC OQA�CT DIRECT TO PLW RELY VALVE 3 N ICWPNALTERNATE Rmewm a commc L IMARS ELEV T 0° .RdCLFA� BEb P�'° WITH @LOCKS ELEV E'0' 0ML TYR FLOOR REg4F 10 TAR�0 � Ir ac WM WAV3 TVP. "ANDRAD WALL SEO9 w am Trac Environme •O • °� •o d •O , A lew MOAndaiw Sbc*LIMM Wi mp,MA 03W f p •e Pools, • o $• y nc. • i ' °''O an Aquatech builder CON STRUCTOOMMOSM i°• '.� •. - ® CQ1M3gMX7tON St1A1l.t90N1+=M TO ALLCiY DWARTKWF CF ® R SMK 9#ML CC 1 TO AXM Q'IDt.mTtDMA.12 . .; MMMMANDSAPETYST:AHQAROd OA-= LAF391ALLC2A14TC?StM0FDCtT1rC1AK2TE 5W EQUAUZER' � �• iCi'Wit'8L1ESi'i1COtO�t . e ' . e PM CX*&TrAWn=&VU H M ANS&IaW ,S 2=STANDARDS' COM MMY : NCO RB['DO I'M 040MM SVVR0(M A= 4" CaTtOLl7�CLAM q ® #{FAUN CWT.APsFWVAL PJ t07t ALL CO>*csta4%L T M AUT0MT1CSUWA=MPfHM GUE48TE Somsmu om Z•0 BARS(EVV) DESIGN ® GLWM94ALL M A NA00a MM AND AFFi111D MMMT=Uy MUD ALL LZC MF PART CEICW TO Int AND A NAIF PARTS SVM UNDER WATER USP T • TM 02M M C *WCW TO LOCAL CtlD281 ND WON A 19 IM UM CMMP SMOM 11 B 3000 P9®35 DAYS • •• '' . .4 REASONAMY LEVEL XWE AND AFFAOMtD NATma GRcumD WNpW • WATEMOCENT RATIO MALL 94ALL NOT ETOL 3 Ill GALS FER • '�, ;• .•t 2 FEET OF T0?Of 000 O ML ANY Vu3r 0A1 WmL pAgt RE SACC CFC KWSLG . PLATE R AAY DI:YA9.AND Dt;QCAd ® Gl,d�llil:L3YA LtG#f T WATEit SFIlAYT1{.'LE TQIS A DAY fC:B ® r FRAME SEVEN DAV& j• FE6!!C! POOL TO 8f- c4,aSrp4c>r�® : :Ct S9' 6N •ecor�-��Nc,� ���� p #3 BARS do O.G ® ® ENVMCN WrAL FOOM DOC BULL BE RBFOIOLE FOR FR ,�� o, BOTH WAYS IN VWH LOCAL MY OR TOVM 0PDR ANM TFC � tL D . A®G Aft • .. a Y�OSTATIC • RELIEF VALVE ' ®t,•�e- PREPARCD Byj +• s #F REQU) :�; OF TUBE € '®COLLECTION ) '•oto' Sy� �H �• 12 9EdObi ROAD � RAVE.SLAB ►�� R J�III 01024 v�5r-•1 PHELAN SIR. STRUCTURAL H " •� If.42538 ® FILL SPOUT, If I4PiPUCA®L.E ORAVWNG SCALE.1 Qt> I ENVIRONMENTAL',% POOLS , INC. MEMBER 184R Riverneck Road a Chelmsford, MA 01824 O 978.256.0200 / 800.696.6976 /.Fax 978.256.6620 E-mail: info@environmentalpools.com a Website: www.Environmentalpools.com NATIONAL An Aquatech Buildert,r# SPA s 11 POOL l�'.. INSTITUTE Design Excellence: With A Personaf Touch The General Terms, Representations,and Conditions on reverse side are part of this Agreement. v NAME (Buyer) MAIL ADDRESS ' CITY STATE ZIP JOB ADDRESS 4A25 . CITY A . V STATE ! ZIP ®9 \ RESIDENCE PHONE OFFICE PHONE Environmental Pools, Inc. (hereinafter"E.P.I.") agrees with the buyer or buyers above (hereinafter the "Buyer") to construct a swimming pool and/or spa in a good and workmanlike manner in accordance with the following terms and specifications. DIMENSIONAL SPECIFICATIONS l t� �„ �- kc- Width I Length U , Shape = Depth to °e r7 GENERAL CONSTRUCTION SPECIFICATIONS MISCELLANEOUS 1. Structural engineered plans.:.........................I..........................................:::INCL` 51. Raised Bond Beam: Tile Stone 2. Pool layout plans '....................................... INCL 6" 12„ ie,,.., 18" 3. Layout pool for Buyer's approval ................................................................INCL. 52. Start-up chemicals: Initial.start-up and follow-up instructions ....................INCL. 4. Set pool elevation for Buyer's',approval ......................................................INCL. 53. Water Condition f' $ 6� 20 tons of 1.5"stone 5. Perform normal excavation a° _Z74-04 0 ""`"" '"" `"®' and remove soil on day of excavation only...... C Additional stone at$ per load...:................................,.,..,..,....BUYER 6. Access wall or fence: removed by: t.. 54. Clay soil-$ ;,,,,,,,,,,,,,,,,,,,, ..,':°! t replaced by: �r "-' ` 7. Trees in access and working'area to be cut down so that the stumps SALES TAX & INSURANCE � do not exceed 2'in heig . . BUYER "'..........""""""""""' 55. Payment of all sales tax on pool components and accesso ies..................INCL. 8. Remove from site loads of:trees, shrubs, stumps, asphalt, 56. Motor vehicle insurance;workers'compensation insurance concrete,and other debris or and general liability insurance .................................... 9. Hand form and shape pool...:.......................................:..............................INCL.. 10. Removal or relocation of cesspool, septic tanks, leaching fields, 11.'------- ADDITIONAL SPECIFICATIONS sewers, pipes and utilities(overhead/underground) ........................... :.BUYER 11. Steel reinforcing per engineered plans....................................................nNCL. 57. !'�1#4-r l Af B L6X M g o meet or exceed local or state codes..........liyCL` 58 12. Engineered unite structure t 13. Watercure unite shell twice daily for seven days................................./OYER .y y � _ ���..��^^^--- \ ACA 14. Install continuous bond beam around skimmer ,/ fNCL. 690. rWQ� � i �servi ,.: 15. One set of shallow end steps with 4'bench..... ..044?.. ............INCL. 16. Swimout or loveseat 4 Fr PM L 17. Install 6"band of Frostproof the.... ...0V.. .......... ..I CL. 61. F rpt 18. Pavers, Bullnose Brick, or Bluestone 19. Cantilever form for deck o 4 20.. 2backfilling and grdmg deck area only: :...:.....:..........� ..INCL. 63. 21. Pool interior finish...�R/S�'T' 9? J�Tl�li'� 11?�.�tB . . INCL. _ - -22.-'clllui of inti!: ro. tl �:. . �•_. a� ,' �� �, :ate.-. 3L,YER. 9 �? P p Y after,thtenor'f�rrlsh.....:........:..,. .:..:.:..:.......:.. 65. ... _... HYDRAULIC & FILTERING'SPECIFICATIONS:; POOL DECK PRICES SUB-BASE MATERIAL IS NOT INCLUDED. Yp 23. Approved deluxe filter: T e, / K 41rSize � �R9'��/�$' ,Nhz*iq 24. Pump and motor: Type.; Size / Decking square footage: TP e Y g 25. Pressure test all pool piping.':.......................................................................INCL. at' Other: '� � � .. � 26. Hook up all water lines from filter to pool................ •� .............................INCL. ... 27. Non-corrosive PVC plumbing throughout..............:.....................................INCL. 28. Hydrostatic valve " IN 29. Provide return inlets for filtered water to pool �� .:...... ............ ...INCL. PAYMENT 30. Main drain suction line with grate.. 4rhr... T1... ®1 ..........:...INCL. 31. Deluxe Skimmer Including Weir Gate and Large BaskeQ;�..114 ........INCL. The Buyer agrees to pay E.P.I.the following Contract Amount for E.P.I:s P plumbing e INCL. P g 9 tment. 33. U to 30'of lumbin between filter and skimmer......................................�• g mer................ .. .. 32. Vacuum fitting outlet in skim . .. performance of its obligations under this Agreement. 34. Pre-cast pool for ad equipment P P .............................................................:..INCL.. PAYMENT SCHEDULE 35. Backwash line..............................................................................................INCL. rh Contract Amount $ 701 ® 30%Day of Excavation AUTOMATIC EQUIPMENT Z, Deposit 40%Day of Gunite $ 36. Automatic pool cleaner: Type tis 5 W) !ll o BALANCE $ 25%Day of Tile $ 37. Stub plumbing for future pool cleaner .................,.......4................................INCL. 5%Day of Interior Finish $ 38. Floor recirculation system ytw "we .+ ' 39. Automatic chemical feeder ...................................� ....INCL. TOTAL $ 40. Apt ornated Pool Controls t --rcqb ta Aiva TERMS AND CONDITIONS THE BUYER UNDERSTANDS THAT BY SIGNING THIS AGREEMENT,HE OR SHE ENTERS INTO A CONTRACT WITH E.P.I.AND THE BUYER CONCERNING E.P.I:S CONSTRUCTION OF A SWIMMING POOL HEATER & UTILITIES POOL,MEETING THE SPECIFICATIONS CONTAINED IN THIS AGREEMENT.ANY CHANGES IN ANY k" OFTHE TERMS OR SPECIFICATIONS OFTHE AGREEMENT MUST BE MADE IN WRITING SIGNED BY 41. Deluxe pool Heater: Size s ��t Make "� - E.P.I.AND THE BUYER,AND NO VERBAL CHANGES IN THESE TERMS AND SPECIFICATIONS ARE Indoor/Outdoor E Nat/Pro AN APERMITTED. Fuel connections,ons, heaventing, fuel storage tanks, permit............ �UYER.� >. AS PART OF ITS OBLIGATIONS UNDER THIS AGREEMENT E.P.I. IS PROVIDING THE BUYER Wltti 1 O conduit.. f.,�. �r.'. ...........INCL. WRITTEN GUARANTEES REGARDING THE SWIMMING POOL WHICH IT WILL CONSTRUCT PUR- 42. Install underwater light(s), each 43. Electrical bonding Of pool as,required by city or town code Mgrk± SUANTTOTHIS AGREEMENT.THESE GUARANTEES ARE CONTAINED IN A SEPARATE DOCUMENT 44. Electrical wiring and connection up.to 75'from service panel _ WHICH IS PROVIDED TO THE BUYER. Pool over 75'at$15.00 per foot,. -jZ1UYE0 THE BUYER HAS THE RIGHT TO CANCELTrIIS AGREEMENT AT ANYTIME BEFORE MIDNIGHT OF Heat Pump at$18.00 per`:fOOt THE THIRD BUSINESS DAY AFTER THE DATE"ON WHICH EITHER THE BUYER OR E.P.I.HAS SIGNED THIS FORM BY GIVING WRITTEN NOTICE OF CANCELLATION TO E.P.I. HYDRO THE APY S A THE BACK OFTHIS CONTRACT CONTAINS IMPORTANTTERMS AND CONDITIONS.THEY ARE PART OF THIS AGREEMENT.READ THEM. 45. A ach tl 4,1. Hyqr ate R ed i9 t I ACKNOWLEDGE THAT THIS AGREEMENT Is A LEGALLY BINDING CONTRACT,SUBJECT ONLY TO BIO r' er p t THE ABOVE CANCELLATION PROVISI NS,AND I CERTIFYTHAT I HAVE READ AND AGREETO ALL A Itl pe ' , TERMS AND C (TIONS F THIS REEM T. ENVIRONMENTAL POOLS, INC. ACCESSORIE m BUYE BY: v 46. Deluxe cleaning tools (18"nylon brush, hand leaf,skimmer, thermometer, pole,test kit, deluxe vacuum) ..............................................INCL. BA 600 UYER 47. Diving board: Size'! -~ Color C dMlf 00 48. 3-tread S.S. ladder/handrail!� DATE DATE 49. Pool slide: Size!' Color 50. All jigs installed by decking contractor or buyer . VC�C�I,UIfWLif'iS� ��'�C�'�.!I�JU''i'JcJJ V�If�(U��l it GREAT LAKE LN. - Soo 0 0 cn N 275-11" w � � LOT 3 I \ �\jHOF4q00 i Fence with Self Latching,Self Closing Gate 1" \ 2� 1, MICHAEL to meet all local and State Codes s I \ � J. N —� 1 78,$" SERGI 234'$" 0 q No.33191 y y ROFESS�O�P� N �P001 EXIST.FND. �NOSURvV(� /22'x 38 TOF= 198.20' 100'BVW I SETBACK 167'-2" 377.6' I THAT THE PRIMARY STRUCTURE FOUNDATION LOVATION THER OTIFY RIZONTAL SETBACK REQUIREMENTS OF THE LOCAL CONFORMS TO APPLICABLE ZONING BY-LAWS IN EFFECT WHEN CONSTRUCTED. CLIENT. TKZ,L LC (THIS CERTIFICATION DOES NOT CONSIDER ANY OTHER RESTRICTIONS SUCH AS COVENANTS,WETLANDS,EASEMENTS, THIS CERTIFICATION IS MADE AND LIMITED TO THE ABOVE CLIENT ORDERS OF CONDITIONS,ETC.)THIS DRAWING SHALL NOT BE USED BY THE CLIENT FOR ANY PURPOSE OTHER THAN THAT OUTLINED LOCATION: NORTH ANDOVER,MASS. ABOVE,EXCEPT WITH THE WRITTEN PERMISSION OF CHRISTIANSEN &SERGI INC.FURTHERMORE THIS DRAWING IS THE COPYRIGHTED DATE: 7/10/15 SCALE: 1"=100' PROPERTY OF CHRISTIANSEN&SERGI INC.AND ANY UNAUTHORIZED USE IS PROHIBITED.CHRISTIANSEN&SERGI TAKES NO RESPONSIBILITY FOR THE UNAUTHORIZED USE OF THIS DRAWING OR ANY INFORMATION CONTAINED HEREON. PROFESSIONAL ENGINEERS & LAND SURVEYORS CHRISTIANSEN 8 SERGI, INC. 160 SUMMER STREET, HAVERHILL, MASSACHUSETTS 01830 WWW.CSI-ENGR.COM TEL. 978-373-0310 FAX. 978-372-3960 DWG.NO.:13114.001.014 i A n North Andover MIMAP September 8, 2015 ®96o-QE383; E137'C-oOo r#F3.911-,- v 046(t=-0080`. 09 :0 Q082� Q37 Cr07 ) � 037tG @00.6 �jRl #�q�0960-0079; 0 00700®3) #1.34',1 #till50 96° l�oo� ®9610=0'048; #72? 239, Y 0961@-()078:) 2g0 39 97 97 .o #_5_6j150' oad Gr. On r 37TCou22 r -�664 #09610r0005:alu �ltr � � � � -•, ultr. t .I yaltr :1 ® 03r7JYC0018� a, •. :c:-_.., it ; 5 � 046'O 0091 1- s 46 O OO2Ot ,3du S E 5V.'. .: �.lu �u •�- - au cc' �3ltt •I ulu t #_447 .+-�. •:.::::. � �I I #�4511iJxr 09:6. OED42t, #455 #454 a,, uUr tltr � �r R #460 1u,09�-6_;4_.OQ9 ! � ttl iFZr .till. t, #110 496 0-005,6' #465\ )u 76 X04 '0 4#,m,, �. 6 91 .r _ � #480) 490 t `U` = 1M�a�ter�Protect 0 � r 06:0 Q 052 96�0-004 - ' '. EQ961O Q05T i - #40 ^®46.0-0041 I � r#2°4 #^'•100 ._°_. ®3C002 # �i;6'196�@�"�022'1; . :096'0=062 F"pr f � ,�' � •.'.09610=t)Q5@" /�#/ 096 0-''0063 09601061 .. 096Q .005t9} 019 U MVPC Bo Wetlands Zoning 0 Busine s 1 District Municipal Boundary Exempt Lands N Busine s 2 District Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, — Rail Line NBus!—s 3 Dist d Meters Data Sources:The data for this map was produced by Merrimack Interstates Y Busine s 4 District NORT1/- Valley Planning Commission(MVPC)using data provided by the Town of I O Genera Business District G! - •u 9� - North Andover.Additional data provided by the Executive Office of SR O Planne Commercial Dev_ - ��� ,.�� ? ee n � Environmental Af(airs/MassGIS.The information depicted on this map is p Corrido Development Dist 3' - L for planning--Roads - E Corrido Development Dist Q _ to P 9 Purposes only. r may n.THE adequate for legal boundary definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER t t Easements O Corrido Development Dist 1I A MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING ❑Parcels L9 Induslri I 1 District 41 ; THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY p Induslri 2 District Zoning Overlay Q Induslri 13 District #no OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT 0 Adult Entertainment O Industd S District ♦ <«« .. > ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF Downtown Overlay District Reside W 1 District THIS INFORMATION ©Historic District - - O Reside ce 2 District Ifs Q 11�- 0 Water Protection 1,R—ide ce 3 District wCHUs -- - O Hydrographic Features de ce 4 District - - -Streams 1"=191 ft A •de ce 5 District TTT de ce 6 District --a, esidential District - - The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesdgadons UT 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ) n VI 20A[ ME7rtNL Address:�� City/State/Zip: C_JhQ1 wtSFe"rj H4 Phone #: Are youaw employer,?Check the appropriate-box: Type o oject(required): 1. am a employer with 2.s' 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7• Q Remodeling strip-and-have-no-employees These-sub-contractor-s-have 8. Demolition working- for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp. insurance 5. ❑ We area 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 I I.0 Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.E]Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13'®pthertw�c P6d *Any applicant that checks box#I must also 611 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. ?Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. _ 01` Insurance Company Name: kqi&o (-irjxr 6ax4t.mC_ &_)%.d,4rjv Policy#or Self-ins.Lic.#: j;-q Yui G-®-1-,Z r q Expiration Date: Job Site Address: /zeVT Z4 k*3 t4AC City/State/Zip: 0,Arrlv*t�tti fj 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 of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cern nder the va' and pe of perjury that the information provided above is true-and-correct. Si ature: Date: - 7.0 t S� Phone M Offic7enDo not write in this area,to be completed by city or town official City Permit/License# Issuin (circle one):1.Bo2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector6.OthContaPhone#: Information and Instructi-ons i 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,constriction 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 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 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia DATE(MM/DD/YYYY) .4 o® CERTIFICATE OF LIABILITY INSURANCE 5/12/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CER11FICATE 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 pol owes)mustent. A statement on this certificate does not confer rights to the aendorsed. If SUBROGATION IS WANED,subject to the terms and conditions of the policy,certain policies may require an endorsem certificate holder in lieu of such endorsement(s). CONT PRODUCER NAmE; Service Team AIMS Insurance Program Managers, Inc. PHONE . (602)635-4848 FAX Nol:(480)991-0634 1418 N Scottsdale Rd %RDRD L .serviceteam@aimsinsurance.com Suite 100 I INSURER AFFORDING COVERAGE MAIC# Scottsdale AZ 85257 INSURER A:Sartford Accident and Indemnity 22357 any 29459 INSURED INSURERB:Twin City Fire Insurance Comp Environmental Pools, Inc. INSURER C: 184R Riverneck Road INSURER D INSURER E Chelmsford MA 01824 INSURER F: REVISION NUMBER: COVERAGES CERTIFICATE 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 POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE pOUCY NUMBER MMI D MM/DD EACH OCCURRENCE $ 1,000,000 X COMMERCIALGENERAL ''LIABILITY I j DAMA ETO 300,000 A, CLAIMS-MADE I.X i OCCUR PREMISES Ea occurrence $ -� -j 5/14/2015 5/14/2016 MED EXP( one $ 5,000 590ENOJ2160 PERSONAL&ADV INJURY $ 1,000,000 GENERALAGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: 2,000,000 n PRODUCTS-COMP/OPAGG $ X POLICY U JECT 17 LOC $ OTHER: COMBINED SINGLE UMIT $ AUTOMOBILE LIABILITY Ea accident BODILY INJURY(Per person) $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS ! PROPERTY DAMAGE $ NON-OWNED ( Per accident HIRED AUTOS ! AUTOS $ UMBRELLA UAB I OCCUR EACH OCCURRENCE $ EXCESS UAB 171 CLAIMS-MADE AGGREGATE $ DED RETENTION PER DTH- WORKERS COMPENSATION i X STATUTE ER AND EMPLOYERS'LUU)ILnY Y/N E.L.EACH ACCIDENT $ 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE N/A OFFICER/MEMBER EXCLUDED? i 59wE0J2182 5/14/2015 5/14/2016 E.L.DISEASE-EA EMPLOYE $ 1 000 000 B (Mandatory In NH) M yes,describe under I E.L.DISEASE-POLICY LIMIT $ 11000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more apace is required) This certificate is only a representation of coverage afforded by the insurance companies noted on it. Terms of coverage are defined in the policies[ies] shown and those terms may or may not comply with the requirements of any contract entered into by the named insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Kimberly Birk/KAT ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(2o14ot) tf (94,�pam7nanreea o�C%�LaQaac�uaelZ Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR egistration ;107083 Type: Expiration 112W 4.6 Private Corporati; ENVIRONMENTAL POOLS INC i j Andrew Everleigh E 184R Riverneck Road Chelmsford,MA 01824 Undersecretary i