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HomeMy WebLinkAboutBuilding Permit #014-2017 - 26 STANTON WAY 6/6/2016 r _ p10RTM (�� I„ BUILDING PERMIT 3�0 "T -D �b;i+ LAP, 5 1✓ TOWN OF NORTH ANDOVER o . WPPLICATION FOR PLAN EXAMINATION I _ " ®� J Date Received Permit No#: WAY— C Date Issued: 1' IMPORTANT: Applicant must complete all items on this page LOCATION PROPERTY OWNER `SILO. W*VMI"/IV Print 100 Year Structure yesno i MAP PARCEL: ZONING DISTRICT: Historic District ye no Machine Shop Village ye no l 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 Lui►rotMIM&- _ ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed-District [1 Water/Sewer_—__ DESCRIPTION OF VjtORK TO BEP FOR ED: Ide 'fication- Please Type or Print Clearly � OWNER: Name: 1ILL k%) h-/L) Phone: 71 Address: l-?� Contractor Name: U 576M 65, /r�'. Phone: Email: /VeHITO CL45 L ; Address: M&I Alf ow Supervisor's Construction Li-re.-nse: C j'(� (a, Exp. Date: . t Home Improvement License: �� �Sl,( :, Exp. Date: 11 ARCHITECT/ENGINEER _ Phone: Address: 5UI�IgaJ�bAReg. 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: $ �ffia" FEE: $ Check No.: "��o Receipt No.: 11 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund - - - _ - of contractor - Building Department appropriate ro The following is a list of the required forms to be filled out for the a pp p permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits i 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 l 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) 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 ry;lcidde Sprinkler Plan And Hydraulic Calculations (If Applicable) -' Copy of Contract 2012 IECC Energy code._ Engineering Affidavits for Engineered products ISIOTE: 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 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL f Public Sewer ❑ Tanning/Massage/Body Art ❑ Swunming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS )Z6ZGI1 CONSERVATION Reviewed on 1 Co Si nature COMMENTS c��eoQ W��� l� <n v-L� e-y, k -s '1 Aj , p r `\ I.C�Ut �1 C..�'�-y ( S HEALTH Reviewed on Signature COMMENTS am � T Zoning Board of Appeals: Variance, Petition No: Zoning Decision receipt submitted yes Planning Board Decision: Corr "z;-„is I Conservation Decision: Comments Water& Sewer Connection/Signature& Date Drivewav Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPReTMENT um set r on site' �- �,Ternp,-®�, iLo ted at4Main St eet; 'F:71e Depa n°sgnure7d.�,"ate COMMEN S -- Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Deter location, mast or service drop requires approval of Electrical Inspector Yes No DANCER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A–F and G min.$1oo-$1oo0 fine NOTES and DATA— (For department use) 2CC---j r'j P--eA w C. l �j�na–H-rtA— LH AGI t � -CJL ® Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 t Location Gja No. Df q — 2-0-1 Date • - TOWN OF NORTH ANDOVER � • m Certificate of Occupancy $ �. Building/Frame Permit Fee $ '� Foundation Permit Fee $ Other Permit Fee $ 4 j TOTAL $ fx i t 1c� Check# .I r v. / _� 300 '� Building Inspector TORY BIANCHI e, ®® 373 Shattuck Way TM {_ Newington, NH 03801 CPO#03-31294 ' Cell 603.817.4644 116, tbianchi@custompools.com ` 9f; www.custompools.com Enter construction cost for fee cal - North Andover F@@ Calculation Construction Cost 48,079.00 m $ - $ 576.95 Plumbing Fee $ 72.12 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 72.12 Total fees collected $ 821.19 26 Stanton Way 014-2017 on 6/6/2016 inground pool BUILDING PERMIT NORrN ��'(Z LE D,�O gtiO LA TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION . O ip ��J�O� OO {�"1 Date Received 1(J �7 74A�R�r.ED repy(y Permit No#: �' 1 gSSACH�1`�'�� Date Issued: ( 1 I ORTANT: Applicant must complete all items on this page LOCATION �l( V IJO�.PROPERTY OWNER �I6M i VA/ Print 100 Year Structure yesno MAP PARCEL:�Z ZONING DISTRICT: Historic District ye no Machine Shop Village ye 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: ❑ Demolition ;K _ MirUG a`Septl ®pVl/elF � 000d Iain mC]�Wetlands, 01Natershed.DstrlcfP *Water%Sewe_r r DESCRIPTION OF RK TO BEP FOR ED:� �rU✓'ill TE- 4yj flkmk_ t> Identification- Please Type or Print Clearly OWNER: Name: LCLi�I�I /U Phone: Address: � � f/V� l � fZ!�9 Contractor Name: ()U5J-(VJ P /M, Phone: Email Address: rU 1 Mb 1 Supervisor's Construction License: ���� r ,) Exp. Date: Ozz. �� ll Home Improvement License: 2 Exp. Date: ARCHITECT/ENGINEER i r5��� � S is Phone: 03 -OIL/) t Address: 5U&4a Reg. No. /7� FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ 77— Check No.: ��o Receipt No.: 1 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund i ,CRY BIANCHI Plans Submitted ❑ Plans Waived 373 Shattuck Way Newington, NH 03801 TYPE OF SEWERAGE DISPOSAL m ��---- ; v�' CPO" 03-31294 Public Sewer Cell 603.817.4644 Tannin1assage1 o well ❑ Tobacco Sales _ tbianchi@custompools.com Private se tic t etc. ( S� 9 www.custompools.com P Pennanent Dumps '-" THE FOLLOWING: SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT Reviewed OnSignature_ _d (A Lv*� COMMENTS N010tL �a 1ST Z6 ZC�� 11 � CONSERVATION Reviewed on / Co Signature COMMENTS D05,Qj C3 _czz <` 5 O V,,,� 2`,� i S C ` 1�$_e.�le` G�v� I S W 1 Loo Su` + dam,'i y . HEALTH Reviewed on I Si nature ff^^ I v� lII COMMENTS �U` � j � Sl SQ� .� 5 � ✓' Zoning Board of Appeals: Variance, Petition No: Zoning Decisionlreceipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRTR MENT T°e l ,mp ter onsiteyes no Located at 1►24 IVlain S reet v °� ` Fire Depart em nt signatu!de . t . � 14 r 7 NORTf� - W ic ve- 2 � z oh , ver, Mass, COC KICHE WICK S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System �THIS CERTIFIES THAT 7a..k. .I..........0"&. ....................................................,, BUILDING INSPECTOR Foundation. has permission to erect buildings on . ............WAY— ............. Rough tobe occupied as .......1.0.......... !fFa j.........pool.................................................................... Chimney provided that the person acceptin is permit shall in every 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST TIO Rough Service ... ....... .. .... .... ... ......... ....... ........ Final BUILD INSPE TOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. CONTRACT# POOL SIZE x CONTRACT DATE c to POOL DEPTH _ x SALESMAN 8 POOL SHAPE 1+) POOL CODE ) 1PCV OO �InC. SPA SIZE i� x SPA CODE SWIMMING POOL CONTRACTOR SPA�<_ATTACHED SEPARATE INDOOR OUTDOOR 373 Shattuck Way Newington,NH 03801 RESIDENTIAL COMMERCIAL 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 S OF THIS DATE OF ACCEPTANCE BY CUSTOM POOLS PHONE1 G� AND,NAME HEREIN TERMED OWNER CELLPHONE ADDRE t�w CELLPHONE CITY f ST ZIP EMAIL ? EMAIL �. GENERAL SERVICES BY CONTRACTOR POOLE UIP NT 1. Standard structural engineering plans and specifications. 40. Cleaning system ,� es❑no 2. State construction permits if required. 41. Filter(s) , yes❑no 3. Hand forming and shaping of pool and/or spa. 42. Skimmers Z_ Returns -It> ,yes Ono 4. Excavate pool and remove dirt on day of excavation. 43. Pump(s) yes❑no 5. Install non-corrosive PVC plumbing throughout pool. 44. Heater(s) C J\ i yes Ono 6. Install dual main drains with hydrostatic relief valve. 45. Light(s) f - es❑no 7. Set filtration equipment per contract and connect to pool plumbing. 46. Controls&Sanitation l' es❑no EQUIPMENT TO BE INSTALLED WITHIN-Z-5- FEET OF POOL 47. Dyes Ono 8. Install steel reinforcing throughout structure. 48. ❑yes❑no 9. Install gunite shell to meet or exceed city/county/state code. 10. Pressure test all plumbing and equipment. SPA E UIPMENT 11. Start up pool,provide instruction,manuals and start-up kit. 49. Jets yes❑no 12. Clean up construction debris. 50. Light(s) - iED yes❑no 13. Pay state and federal taxes per law. 51. Heater yes Ono 14. Provide public liability and workman's compensation insurance. 52. Circulation purryes Ono s 15. Provide property damage insurance during construction. 53. Boost pump(s) yes 0n t 54. Skimmer(s) S OWNERS RESPONSIBILITIES yes El no ./.�1„Y1`' S5. Main drains J yes Ono 16. Provide local permits for pool construction. J6 56. If raised spa specify yes❑no 17. Provide access to pool location for construction equipment. 4 18. Provide water and power for construction. GRADING AROUND POOL FOR DECK 19. Approve pool elevation and verify location of property lines. Because all pool sites are different in the amount of time and the amount of 20. Pay for any additional costs incurred due to underground obstacles,rock fill required,we cannot give you a fixed cost for this work at time of contract or water,etc.$600.00 per load of stone(including machine time). signing.Custom Pools,Inc.charges$125.00 per hour(4 hour minimum)for 21. Pay for any additional costs due to soil with inadequate bearing capacity. spreading fill and grading.The cost of fill is to be paid by the owner at time 22. Electrical,gas and domestic water hook-ups,and heater venting if of delivery or Custom Pools will bill owner for fill at cost+20%. needed. �� J 23. Water curing of gunite shell for at least 7 days. (owner initial) ,&­ 24. Provide water for filling of pool immediately after plastering and to DECK EQUIPMENT TO BE INSTALLED BY: brush new plaster surface for 2 weeks as instructed. DECK ANCHORS TO BE INSTALLED BY: 25. Provide construction or permanent fencing per local code. 57. Ladders ❑yes no 26. Maintain pool after pool is filled with water. �)5 (owner initial) 58. Railings ❑yes no 59. Diving board ❑yes no GENERAL CONSTRUCTION SPECIFICATIONS 60. Slide ❑yes no 27. Normal excavation with standard equipment es❑no 61. Handicap lift Dyes no 28. 29. Dirt to be removed: ithin 1 mile ❑left on site ❑other❑yes�"po MISCELLANEOUS EQUIPMENT/EXTRAS 30. Specify any items suc as tree stumps,concrete,old pool or decking to 62. Deluxe maintenance kit to include wall brush,leaf skimmer, be removed at time of excavation or any pregrading required.Additional 8'-16'telescopic pole,test kit and thermometer. yes Ono cost to be added to contract._ C� 63. Rope,floats,hooks OyesNo 64. A to Cover ❑Y eso 31. Swimout/loveseat feet ,yes 0n 65. jces 0n 32. Grand stair entry yiyes❑no 66• El yes no 33. Perimeter edge ; %6 ❑yes)9uo 67• Dyes no 34. Standard 6"tile border at waterline )5yes Ono 68• 11yes no 35. Depth markers:on perimeter tile on deck ❑yes*o 69• ED]yes no 36. Accent file ❑yes)gpo 70• Dyes no 37. Other tile ❑yes;�qo 71• ❑yes no 38. Raised beam length height ❑yes'$Qo 72• Dyes no 39. Interior fmish7:MJ,6es Ono 73• Dyes no ADDITIONAL SPECIFICATIONS: PAYMENT SCHEDULE ACCEPTED this day of 20 Contract Amount UiQ by Title: Down Payment Cl��St m Pools'officer Balance Due _ _� �t4 by. 50%Due day of Excavationit I Pool owner or individual responsible for payment of contract 45%Due day of Gunite Application This is not an estimate-The general terms and conditions on the reverse side are 5%Due day of Interior Finish part of this agreement. White-Custom Pools'copy Yellow-will be sent to customer after approval Pink-customer copy(not binding) Vyel O373 SHATTUCK WAY.NEWINGTON.N.H.03901 o a' a' ,s' 3z EXACT LAYOUT BY TORY &TRIAD (803)431.7800 SCALE:VS'=1' G pob. JOB INFORMATION POOL DETAILS .loe RureER: # S-- 15'X30' wAreR oEPne 3'TO 6' PROPERTY LINE : BILL BROSNIHAN c 38016079 SR : KIDNEY 26 STANTON WAY 12.000 OTY)SME: NORTH ANDOVER,MA 01845 Pur> HAYWARD 1 rRORE: 978.590.3041 carer: STA-RITE soE: S7M120 BILL.BROZ000MCAST.NET sISEBwEA: PENTAIR om 2 a sA�Ee vERsaR: TORY BIANCHI rwso: WA RENRRs: 3 +s*s: NIA DIRECTIONS w"1M°""mwi"Y°"osrAno"E"E`; (2) REArPn MLES: 38 HAYWARD BM 250K cuEi:NAT our X *: LED colo I.E3arK 50' 18-RAISED SPA(8'DIAMETER) 95 SOUTH TO 495 SOUTH FSERo IM WA unrrwRcT-6- 4 6JErs EXIT 48 TOWARD MA-125 vAc YES ­SE: 40' 0 LEDWALGHT RIGHT ON INDUSTRIAL AVE YES b 6r CRANRELNu. - SLIGHT RIGHT TO STAY ON INDUSTRIAL corrtaasrstE3s. AQUA-RITE 16V y 6 SPLLwAY VENEER BYDTNERS CONTINUE STRAIGHT ON S MAIN ST sANnZM: WA b L F CONTINUE ON KNIPE RD RAas: WA sti CONTINUE ON BOSTON RD umERe: WA RA,mx:APUPr: WA LEFT ON BRADFORD ST DAvwBDAR BM: WA r O Ss RIGHT ON STANTON WAY ROPE meas: Wq wiRovEanwls: WA 31 w DUILLNVUNDIWNs +aD IST DRIVEWAY ON LEFT POOL 19 SPA FINISH 0(3 APART) ENTRY ST SHARED DRIVEWAY,1ST ON LEFT Pi,.s�c PEARL OR SATIN TBD s eexcN SPECIAL NOTES TeE9 Tl TOO AccENTT : WA '1) APPRowuIE DECK BY n2BD TRIAD mm— TRIAD DECaauTEmAL ,')7 sR AQUA-RITE 16V 0 s'SWe3our RE1VRN(3) saw R(2) cm—mw- TRIAD m AQUA-CONNECT �: WA Eauv S`T EtECTAC BY: WA .( �� aRADaxi: WA r Z rREEsasTaas Sr: WA m x401 SPA DETAILS O suE 8'DIAMETER WATER DEv1N; 42' 6� 9t caoe 501625 sALe: 1,000 wo. AAa: HAYWARD N.P: VS BOOST 4'l• ParER: SHARED 1 BOSTON RD elo'u�ER: SPILLWAY HOUSE KNIPE RD RE S 2 3ETs: 6 ACCESS SMAIN ST Nra omuNwixroBosrATC REares: CHANNEL DRIVEWAY FOGSA _mw SHARED X48 uaRr: SPALED coRo_m 50' YY E CT a wAnx rEVEIER: YES 495S CONTROL BYSIEN3: SHARED _ms: UGHT DETAIL RAaA: 95S S sPA(RASED Tet "� y 3le'STM nE 6•CERAMIC nIE GUNIIE BEAM CONCEPTUAL DRAWING �� �• O i ACCEPTED BY: yTre 06I15I2016 Ly 1 X REVISIONS wAu avuN DRAws PEARL OR SATIN TBD "" < > ! r t r y8 ,4: t N" "A y,z s t 4 �4 t N lp, *' ' t4R` o � } ` �� Cyt r'���'4. �€ �f '��4�t1:���°'iR��a.. �. � �`vai+ yfF U ' '�'.{ `��,�• �\ ��� �. '� `p �^ '�` a•F'� t �`, '�� �� `�. � � ,s \'. ���� �6'°.'Sid .� � 6� ��a3, ''daa s� ��'��; `3 'G ,cry ,� • ;at. .`t , p��{'}'�,,qy,.. ti'�✓�.1�. x � '� �� ,'yg�� �qyy\.ice. �..b�z '1. `' �`�'� C` / .,ar°. �'" �`' � 6, a• w at y •R .*Q V i 17 Yb�. 10 't a x y Aa � C .�.� d Zi. F� t ti a'$ ya y� x ♦ f �fa wk AV VVTP V- AL w ` 1 �,is n t ;ii. 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'i.. ^y�y..i� `€�+ _ ..� y '4�`��\t C� ltf�pYr✓ North Andover MIMAP June 15, 2016 r F� l '061.0-0023 #,T:9: \ �\ 06.1.0-0038 "k 061.0-0058 r Haverhill #.21 51 1 061 06 .0-0025..0-0066 _ d� `a #,23: l 061A,-0.033 sal \ 061.0-0.116 \�°1 06'1.0-0117 \ a #26 \ #_25 ��061.0-0074 061.0-0118 \ 061:0-0034 it 02, #27 Boxford 0.61A-0035 #48 ti 156, ,,061.0-0067 CDD3 #29 #56 ,\ 0,61.0-0036 61.0-0•li9 � �� �� 061.0-0122 061.0, 75 061.0-0123 #31' 06LO-0031 06 1.0t 06.1.0-0121 ! 061.0-0024 #55 SS 061.0-0124 001.0-0007 061.0-0032 #,63 R2 31�, 34.0-0033 061.0:-009;1.. 061.0-..0089 061;0-0093 ##29 Ate. #.61 0161.1070090#53 #,45, #3:7, 95 a ,ane 3p3 034.0-00051p1' wh�t2i�i(Gh��' 11A, 1p� 061.0-0037 #69 061..0=.0092, 034`.0-0041 #67' 061.0-0.0.01 ` 061.070094. 061.0-0095 046 061.0=0057 061.0-0064: MVPC Bo Zoning Overlay Zoning [3 Municipal Boundary 0 Adult Entertainment Distric Busine s 1 District 0 Machine Shop Village Ove Al Busine s 2 District Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, - Rail Line ®Watershed Protection Dist O.Busine s 3 District Meters Data Sources:The data for this map was produced by Merrimack Interstates 0 Historic Mill Area C Businei s 4 District N01111 Valley Planning Commission(MVPC)using data provided by the Town of _ IE)Medical Marijuana O Genera Business District Qt u q� North Andover.Additional data provided by the Executive Office of SR 0 Downtown Overlay District O Planne I Commercial Dev `� O Environmental Affairs/MassGIS.The information depicted on this map is Roads 0 Historic District 0 Corrido Development Dist 3j e _•4 OL for planning purposes only.It may not be adequate for legal boundary Osgood Smart Growth(40 O Corrido Development Dist O ,- -" definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER f-r Easements Q Hydrographic Features O Corrido Development Dist �' 9 MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING ❑Parcels Industri 1 District * THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY Streams 0 Industri 12 District � "s � i OF THESE DATA,THE TOWN OF NORTH ANDOVER DOES NOT -:Wetlands 6 Industri 3 District ; o �� ♦ ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF O Industri I S District • ' THIS INFORMATION Q Exempt Lands Reside ce t District �f,9 no..... 'S Reside ce 2 District SSgGHb f e Rr-idei ce 3 District dai ce 4 District 1"=169ftder ce 5 District Edece6 District age esidential District ' v 12e �po��z���o�2�c�eatit�L 1��C�GiGcrrJJc�u�l��1� Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 123810 Type: Private Corporation Expiration: 4/11/2017 Tr# 263086 Custom Pools, Inc Brian Short -- 373 SHATTUCK WAY --- - — -- Newington, NH 03081 -------.-- Update Address and return card.Mark reason for change. SCA1 Cr 20M-0511.1 [� Address (_] Renewal F-1 Employment 1--�'Lost Card �- Office of Consumer Affairs&Business Regulation License or registration valid for individul use only 7POME IMPROVEMENT CONTRACTOR P >t� before the expiration date. [f found return to: Pegistration: 123810 Type: Office of Consumer Affairs and Business Regulation 'G -Expiration: 4/11/2017 Private Corporation 1.0 Park Play Suite 5170 Boston,M 0 116 Custom Pools,Inc Brian Short ; 373 SHATTUCK WAY Newington,NH 03081 Undersecretary Not va i without signature Massachusetts,Vepartment of Public Safely ` Board of Buil ding Regulations and Standards License:CS-1,66-405 Construction Supervisor ,a 1 1.. DARREL SHORT 373 SHATT LIG SIA t PORTS'hApllTli Expiration: Commissioner 99/Zl;'/$Q'17 Construction Supervisor Restricted to: Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed space. Failure to possess a current edition of the Massachusetts / State Building Code is cause for revocation of this license. DPS Licensing information visit:VVWW.MASS.GOV/DPS I l/4 _joaoa foad06oeoe068t76P699 f/Xo4u H#/0/n/eo/!1e w/woo•o l6006•!!ew//:sdgy . ;Me Cotnntonweadth of Masyachusetts Depaamni of TftdUs&jafAc Iden& I Congress,S`tPee> Suite 100 ° Boston,Mtn 0294-2017 www mass goy/Ma Warkere Compensation Insurance Affidavit:Bnitders(Co ractors/Rtectxieians)P lnmbexs. TO BE 1? THS pMffrMGAUTBCORI V - Please Print L A licantlnformatlon Name(Busi-dOM-izaflonftdividaal): Address: J / Phone# I Moo City/StatelZip: ... pr ' nate I ox Type of oject(het uii ed): Areyou an eraployer4 Checkt(ie�aPP P ¢ q. Q New construction .��(.l employees(Sill sem/°r part-umel. 1: Imn aemployerwith inrmein S. BRemodelift 1- Iamasoleprop[iertororp�°�pandbavenoemployeesworia�say�oih'-IN°Wooer'comp.insurance revired l 9. Demolition 3QlamahomeownerdoingellworkmYsel£[!f° 'CO1°p insamneorrgnieed.lt 10QTinildingaddition contractors toconduatellworkonmypwPertY-Iwiff i1.Q�e�cajrepairsoradditions 4.❑Iamahomeownerandwillbehidog min eeoramsole ensurethatauoontracwmei&,rbmwo kers'CMV-8ti 12:QPlumbingrepairs or additions F4id-mviihno employees. Z`heseasub-coniraciorshadp eu�PlO3'�and havnebw000dncurasdaahadseet I134,Q�ROotoftepails 5. Imng@n,mi,# randIhavChi'cdhe Comp.insmane •. tfi havaexercised1heirrWtoP>ooeml -PmM�iG 6.QWeamaoaWrat(PnandifsR. F iosmanc°require&I andwehavep4ppIayeasworkers'com�- ffieSrwor s'oompensah°nP� n. cytafomi.new sem,appli�tthat°balsab6x#lmustalsoRUout the se'donl>elowsh°wing m�sq a a�davRindicatingsacb us el davitindiaatmgtheyamdoingall to*and8renhlr°rnrmideaantmctora ornottho�ootiiebl - UMO v dro sutimii..' me name of ash cont[a°tins a�st o whe$ier tConhaetoisHmtcheckd&b0Kmust�tta! ti1ep �On°IsbeetshowinS b member emPlayees ffthesulrco rn °rs> eemployees,�raymnstPr°vidaffieirwo reGmap-po c to ees"•Below is•flzepolicy acidjob site B I ain an employer that is pPovM6jgworJrers''cors msatlon insurance for rrry emp Y information. 'q n bsurance Company Name: TY YT ExpirationDaig Policy#or self-ms.Lie. CitylState/zip:lob Site Address: p showing the policy expiration date)• Attach a spy of the workers'c4mpepsation policy declaration age Failure to secure coverageas required under MGL a.152,§25A is a criminal violation punishable by fine np bo$1,500.0 and/or for out_ ne year imprisonment,as well as civil penalties in the fDTM of a STOP WORK ORDERfthe DIA for a fMG of UP insurance a day against the violator.A copy of this statement may be forwarded to the Office of)nvestigati coveaage verification. iliat the inforirrationprovided above is trueand correct I do hereby certify M& tlrepains aradpenalties ofP '9 � � ar I . i Date: sine hone# Offlcitd use only. Do not 1prw in this area,to be complrled by city or folsw qffldaL. . - PerwidUcense# City or Town: Issuing AorRy(Grcle one): 3.City/Town Clerk 4.Ttlectriral Insp edsp or 5.Plumbing Inector 1.Board of Health 2.Bnitding Department 6.Other• Phone#• Contact Person: - 6df a dwo sea ao .600 i3 � �I M 9l•0Z/6Z/9 A6 0 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 6/16/2016 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 Christine Holman, CPCU, CIC NAME: THE ROWLEY AGENCY INC. ACNENo,E (603)224-2562 A/C No):(603)224-8012 45 Constitution Avenue ADDRESS:cholman@rowleyagency.com P.O. BOX 511 INSURERS AFFORDING COVERAGE NAIC# Concord NH 03302-0511 INSURERA:Continental Casualty 20443 INSURED INSURERB:Continental Insurance Co. 35289 Custom Pools, Inc. INSURER C: 373 Shattuck Way INSURER D: INSURER E: Newington NH 03801-2825 INSURER F: COVERAGES CERTIFICATE NUMBER:16-17 all lines 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR D POLICY NUMBER MM/DD/YYYY MM/DD/YYYY X COMMERCIAL GENERAL LIABILITY - 1,000,000 DAMAGE TO EACH OCCURRENCE $ A CLAIMS-MADE �OCCUR PREMISES Ea occurrence) $ 100,000 C4016663366 6/1/2016 6/1/2017 MED EXP(Any one person) $ 5,000 PERSONAL BADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY 7 jE FX LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: 1 $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 B X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED 04016663416 6/1/2016 6/1/2017 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Per accident $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 2 000 000 DED X I RETENTION$ 10,000 04016663433 6/1/2016 6/1/2017 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A LEASED/RENTED EQUIPMENT C4016663366 6/1/2016 6/1/2017 LIMIT PER ITEM: $25,000 MAX LIMIT: $50,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE: Job address 26 Stanton Way 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. Building 20, Suite 2035 North Andover, MA 01845 AUTHORIZED REPRESENTATIVE C Holman, CPCU, CIC/C ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025/gntarrtt I 12FUMAf rA NEW HAMPSHIRE MOTOR TRANSPORT ASSOCIATION P.O.Box 3898 Concord,NH 03302-3898 (603)224-7337 CERTIFICATE OF INSURANCE 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. This is to certify that: Custom Pools, Inc Certificate#: 33 373 Shattuck Way Newington, NH 03802-2825 Is,at the issue date of this certificate,insured by the Company,under the policy(ies)listed below. The insurance afforded by the listed policy(ies)is subject to all their terms,exclusions and conditions and is not altered by any requirement,term or condition or other document with respect to which this certificate may be issued. COVERAGE AFFORDED UNDER WC LAW OF THE FOLLOWING STATE: NH TYPE OF POLICY EXP DATE POLICY NUMBER LIMIT OF LIABILITY Continuous* Extended Policy Term Workers'Compensation 01/01/2016-01/01/2017 P000806NHMTA2016 Bodily Injury By Accident $500,000 Employers Liability Bodily Injury by Disease Policy Limit $500,000 Bodily Injury by Disease Each Person $500,000 ADDITIONAL COMMENTS: If the certificate expiration date is continuous or extended term,you will be notified if coverage is terminated or reduced before the certificate expiration date. NOTICE OF CANCELLATION: (Not applicable unless a number of days is entered below.) Before the stated expiration date,the company will not cancel or reduce the insurance afforded under the above policies until at least 30 days. Notice of such cancellation has been mailed to: NH MOTOR TRANSPORT ASSOCIATION SELF-INSURANCE GROUP TRUST Town of North Andover MA Attn: Bill Brosnihan 26 Stanton Way North Andover, MA 01845 Igoe 4dir I r I� Authorized Representative Concord, NH 603-224-7337 06/16/2016 Office Phone Number Date Issued NEW HAMPSHIRE MOTOR TRANSPORT ASSOCIATION P.O.Box 3898 Concord,NH 03302-3898 (603)224-7337 CERTIFICATE OF INSURANCE 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. This is to certify that: Custom Pools, Inc Certificate#: 36 373 Shattuck Way Newington, NH 03802-2825 Is,at the issue date of this certificate,insured by the Company,under the policy(ies)listed below. The insurance afforded by the listed policy(ies)is subject to all their terms,exclusions and conditions and is not altered by any requirement,term or condition or other document with respect to which this certificate may be issued. COVERAGE AFFORDED UNDER WC LAW OF THE FOLLOWING STATE: NH TYPE OF POLICY EXP DATE POLICY NUMBER LIMIT OF LIABILITY Continuous* Extended Policy Term Workers'Compensation 01/01/2016-01/01/2017 P000806NHMTA2016 Bodily Injury By Accident $500,000 Employers Liability Bodily Injury by Disease Policy Limit $500,000 Bodily Injury by Disease Each Person $500,000 ADDITIONAL COMMENTS: Job Site:26 Stanton Way North Andover,MA 01845 *If the certificate expiration date is continuous or extended term,you will be notified if coverage is terminated or reduced before the certificate expiration date. NOTICE OF CANCELLATION: (Not applicable unless a number of days is entered below.) Before the stated expiration date,the company will not cancel or reduce the insurance afforded under the above policies until at least 30 days. Notice of such cancellation has been mailed to: NH MOTOR TRANSPORT ASSOCIATION SELF-INSURANCE GROUP TRUST Town of North Andover MA Bill Brosnihan 26 Stanton Way _ d North Andover, MA 01845 +(/'` Authorized Representative Concord,NH 603-224-7337 06/21/2016 Office Phone Number Date Issued