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HomeMy WebLinkAboutBuilding Permit #794 - 271 CANDLESTICK ROAD 6/7/2010TYPE OF IMPROVEMENT PROPOSED USE I Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Others: Repair, replacement Assessory Bldg Demolition Other 4 Septic Well Floodplain Wetlands F 1Natershed District ',Water/Sewer _ ;- ►I uw%.r 1r-11Un Ur VVUKK I U t3E PKEFORMED: Y -/-,t I rY-4 1 — '-)-7 ' �D � , Identification Please Type or Print Clea 1 ) OWNER: Name: OL n n S C Phone: S -72a Address: obi C� Cn71';NTR 4CTOFZ Name 7! Fhone,*Nf Address: Supervisor's Constuctlon ticense =_ Exp..; Date:; ` - - 4. Moore lmprovement`Cicense y _ _ Exn. Date -1_ ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ L4 , 01 �2 —f FEE: $ Check No.: via °11^Receipt No.: NOTE: Persons contracting�Gith unre is', ctors do not have access to the guaranty fund Location— No. 7f � Date TOWN OF NORTH ANDOVER Certificate of occu pancy $. —� Bui - Iding/Frame Permit Fee $ Foundation Permit Fee $ 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; efc.) Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM LANNIN/8aD COMMENTS NSERVATION Reviewed o COMMENTS HEALTH COMMENTS S DATE REJECTED DATE APPROVED Reviewed or Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes ,planning Board Decision: Comments .r Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: 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 requ1res. approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NU I t5 ana UA I A — wor department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2010 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.0 And/Or C.S.L. Licenses ❑ Copy of Corrtract . ❑ 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 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: Building Permit Revised 2008 0.1� . . � -" WALL. 2-71 ROUND PARSONS AND FAIA INC. 60 LEWIS STREET . _YN N , MASSACHUSETTS 01902 (7 81) 59.3-7927 13 I E-71i�4nd (D Cb -s'nCk THIS IS A TAPE SURVEY BASED ON THE (`+'n SURVEY -MARKERS OF OTHERS AND THE LINES' OF. OCCUPATION. THIS PLAN WAS DRAWN FOR 0114 8 MORTGAGE PURPOSES ONLY.THIS PLAN WAS REFERENCE: �t NO.T PREPARED FOR RECORDING PURPOSES, DEED.DISCRIPTIONS, CONSTRUCTION VERIFICATION OF PROPERTY LINE DIMENS10 BUILDING UNE OFFSETS, FENCES OR LOT CONFIGURATIONS.ONLY A PRECISE INSTRUMENT SURVEY CAN DETERMINE ALL IHEREBY CERTIFY THAT THEBUILDINGIS) THE ABOVE: SHOWN ON THIS PLAN ARE APPROXIMATELY MORTGAGE INSPECTION, PLAN LOCATED ON THE GROUNDS AS SHOWN THEREON AND THAT THEY CONFORM TO THE DIMENSIONAL REQUIREMENTS OF THE ( (t TOWN/CITY OFtoMpk'00QON:ING LAWS QOM 4activom WH ONSTRUUCT�ED. �:' ,.il^"^+�' �1 1 I SCALE: l"=8o' DATE: $&Jt 4 oousc Prop 6irie C�'gac� PRoD Uwe � �1A a C oQ W o w° U) A ° U m 7 ' U is w gypF• W `° x a O w w W OD cn ro w a p U boid w z w w w m' zv cn O V) V r O z c o �a� c c o 0 O H ;F, C O w_ c� i� :eat c o � E a y b : E c 0 ' urn 4E E Ce co N r ca cm O N ate;=� c H O4D 0 cm O CLC.3 m cm cm dct � O O m V N O G Z ++ m O O C y m = m m t„ o N CDs co t W �s d= c •fyq O C Z CC O ,0 O O 'h VQ V W C7 cr) -0 O 'O S cyo O CLa`HO �- m Co O O O o � Z CD C■ O CO) G C co o, CO) O -0 y O ■O CO m co 0 co H L CL _ ♦-+ CD CD o O d CL �a y C 4-0 C C cc v J ■O �O. O ♦0.. C Z CD V y c C ■ C _c d LLI0 C4 U) 19W W C9 LLI /�WLI/� Y/ N ;� Qo x O w C/) v cf) 0 U CQ 'O p w xC—ca O w C U C w 0 U PO "a a p w C w QU w WC p c2 u co CG CO C Z w y 0 ° z Q v 0 c y- o m C o O O ' w O v CJ Cc p, CC `: z o ` y r ccPJ CD cov: ^� cj c� cr �. E Me L h = CA m N C H' R O � E.S av m ti ID 12 �: z= o cm .. *- -co :moa f/f ' d C Z � O _O f m C3.yZ p :evo� cm Q"m CSc .o = m : o, 3 N COD t F.. MA dt c Z '® v ®v .� O _ 0. LID tv m o y'c O H t S d.=.,m U 0 v .lzv P4 i O O O G CO) O y O L coCL C O CD 0 ccCL CA O V d H C O O C cc C. CA D L O is CD 0. CO) C 0 co O � 3 -a O L o C- cmQ C � C ca J.O O Z v a) C. CO2 C ---inwea{th of Massachusetts tle 5 Official Inspection Form T>` dace Sewage Disposal System Form - Not for Voluntary Assessments Zandlestick Rd. y and Maryann Scarangelo s Name Andover MA 01845 10/22/2009 _. i�nrn State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SAS and all components in good working order B) System Conditionally Passes: ❑ one or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 15ins • 0•..108 Tiiie 5 official Inspection Form: Subsurface Savage Disposal System • Page 2 of 17 ,=lth of Massachusetts �► official Inspection Form - Sewage Disposal System Form - Not for Voluntary Assessments t:ck Rd. =ccaess and Maryann Scarangelo Name �r t Andover _ MA 01845 10/22/2009 ' ;=yawn State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand -sketch in the area below ❑ drawing attached separately Title 5 official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 page 1 esident'ial Until Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 271 Candlestick Rd. Property Address Gregory and Maryann Scarangelo Owner's Name --ed for every North Andover MA 01845 10/22/2009 .�..-.. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. r✓n A. General Information Inspector: Chad Jablonski Name of Inspector Jablonski & Sons, Inc. Company Name 167 Willow Ave. Company Address Haverhill City/Town 978-360-9358 Telephone Number B. Certification MA 01835 State Zip Code 4574 License Number I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority /e/�3 Date The systerolinspr shall submit a copy of this inspection report to the Approving Authority (Board of Health or ) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 09108 Tide 5 Official Inspection Fonn. Subsurface SL -Nage Disposal System • Page 1 of 17 06/03/2010 08:08 FAX 9782234038 Ia 0021003 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Industries of Massachusetts Mutual Insurance Company Burlington, 11111meachunft (8" 676.gm I CI No 281ee POLICY NO. 11 1 1 ITEMPRIOA NO. ImCdolismi2bas 1. The Insured Orth Brim Pool Builders Inc Me1Mnp Add*w. 21 Threrlon Avenue Haverhill MA 111!138 010. 8"d Tow ,x ft C&A* awls Zip Codi ❑ Inowutd ❑ Par wmwp ® Corpntlon ❑ omr FEIN 208882688 Oftr workplaces not shown above: 2. The poa4y, perlod Is fmrn02HOf2010 to 02!10/2011 12A1 am. Standard time a1 the Insured's mWiing addaw. 3 A. Workers. Compensation Insurance: Part One of the policy applies to the Workers compensation Law of the states listed here; MA B. Employers Liability Insurance: Part Two of the policy applies to work In each state HMO In Item 3.A. The Ilmits dour Mabliftyunder PadTwo are: Bodily Injury by Accident $ 10-3,000 each merit Bodily Injury by Mom $_ 500.000 policyl►mit Bo* Injury by Disease 3 10 0, 0 0 0 each emp1oyee C. Other States tnlwrence: Cbvorepa Replaced By Endorsement WC 20 03 04A D. This policy includes these endorsements and schedules: SEE SCHEDULE 4. The premium for this policy Wn be determined by our MAamals d Rules, Chuffications, Reis and Radng purrs. All intonation rWred below la subject to varif Mon inti dwoe by aunt. Claestilcatlone Premium Baste PAN r omr r_san>am pmrn r rransum a t.O rAw Pers1w aeftld OOd� TeW Irma!! s.1 ARMW N0' Ro"W"MIMn Rsmurr EW Prtmh,m INTRA 603900 '$91.00 G?� Q SEE ,94N QF INFO TION PA13E Minimum premium 5 5W.00 r omr r_san>am pmrn r rransum a rw.vv As. Indko ted, intellm adjusbnanta of premnan 611011118 nhsde: Dwalt Premium $ 787.00 ® Annually Q Sernl Annually ❑ Quartedy ❑ M01 r MA A9rrt Chs. $4" x 72000% '$91.00 G?� Q 01/1010 Tnle poky, ImIuding all endorsemeft 18 hereby coprrte*Nd by - Mlnurtr�e a Dere WVOOV KIND P44GNd CLAIM NAME BAFETY STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP IF&M $ Rou*e InmuUm 1 l� MA 8317 606 A erwy Joe 1.11.1 # 208 Mn WC 00 00 01 A (11-88) Inelutls� aopyrhp+tsd mrrurls) of d+s Ww�r Caunau an �a,rrpsaaagon Mtwranos, Daanvem 01923S C� reed wish Its per�ealan. f � 08/03/2010 08:09 FAX 9782234038 16003/003 MASSACHUSETTS ASSIGNED RISK POOL REQUEST FOR CERTIFICATE OF INSURANCE Use this form to request a Certificate of Insurance from an Assigned Risk Pool Carrier. Please provide all of the requested information, including the facsimile number(s) of the person or persons to whom the Certificate of Insurance should be issued. If this form is fully and accurately completed, the Certificate of Insurance will be issued and distributed by facsimile to each fax number provided below, within two (2) business days of the carrier's receipt. This Form may be mailed or faxed to the Assigned Risk Pool Carrier. To obtain each carrier's contact information refer to the Certificates of Insurance section located in the Producer Community section of the Bureau's website (www.wcribma.org). 1. Name, address, telephone number and facsimile numbw at the iNURED: Name: North Shore Pool Builders, Inc. Mailing Address: 21 Tiverton Avenue Haverhill MA 01835 Physical Address: 21 Tiverton Avenue Haverhill MA 01835 Phone: (97$)235-4959 Fax: (866)470-0944 1. Name, address, telephone number and facsimile number at the CERTIFICATE HOLDER: Name: Mailing Address: Physical Address: Phone: Marianne Scarangelo 271 Candlestick Rd, N. Andover, MA 01845 Fax: (978)208.7226 2. Name, address, telephone number and facsimile number at the PRODUCER Name: Fabri & Rourke Insurance Agency, Inc. Mailing Address: 153 Andover Street, Unit 9 208, Danvers, MA 01923 Contact Person: Bill Fabd Phone- 978-223-4037 Fax: 978-223-4038 3. Policy Number, Policy Effeadve Date and Policy Expirat/on Date If a Certificate of insurance is needed for more than one policy term, provide the Policy Number, Effective Date and Expiration Date for each policy term. if the policy has not yell been issued, you must attach a copy of the Notice of Assignment. Policy Number: 601159301-2010 Effective Date: 211012010 Expiration Date: 2/10/2011 4. List any special requests for optional coverages /endorsements (see Page 2 for listing of coverages available in the pool and the conditions of availability) or additional information (including changes in exposure not yet reported to the carrier) that will assist the carrier in the Issuance of the Certificate of insurance. NOTE: An additional insured(s) shall not be listed on any Certificate of Insurance unless such additional insured(s) is a named insured on the policy. 6/3/2010 10:06:53 AM 8982 2 02/02 CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYY) 06/03/2010 THIS CERTIFICATE IS ISSUED AS A NATTER OF INFORMATION ONLY AND CONFERS HO 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), AUTHORISED 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 E'abri & Rourke Insurance Agency Inc 153 Andover Street # 208 Danvers, NA 01923 CONTACT IUM: PNOAE PAR (A/C. Be. Ext): (A/C. Ra): E-MAIL ADDRESS: PRODUCER CUSTOMER IDR. INSUREDS) AFFORDING COVERAGE RAIC A INSURED North Shore Pool Builders Inc 21 Tiverton Street Haverhill, MA 01835 INSURER A: A. I .M. Mutual Insurance Co INSURER B, INSURER C: INSURER D: IHSUBER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW RAVE 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, TRE INSURANCE AFFORDED BY THE POLICIES DESCRIBED RENEIH IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AHD CONDITIONS OF SUCH POLICIES. LILTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAM. Ia.r Lt. TYPE OF INSURANCE POLICY NUMBER POLICY EFF ,RRlDD/TYrr> POLICY ERP caRnn/tTxr( L3MM GENERAL LIABILITY EACH OCCURANCE 6 ❑COt3•fERC IAL GENERAL LIABILITY 1:1DCLAIMS RADE OCCUR DRMUE TO REDTED PM24ISES (Ea.POrurrenae) 6 MED IMP (Any one pexaon) 6 PERSONAL 4 NOV INJURY 6 OMRAL AGGREGATE 6 GSW L AGGREGATE LIMIT APPLIES ER: PRODUCTS - COMP/OP ARO 6 PROJHCT PW.ICY LOC 6 AUTOMOBILE LIABILITY C@IDMD SINGLE LIMIT (ea accident) 6 �ARY AUTO BUILT IRXURY (Der Nerem,) 6 ALL OWNED AUTOS BODILY IN.TURY(Der amident) 6 SCHEDULED AUTOS FIRED AUTOS PROPERTY DRMASE (per aoOident) 6 ANON -OWNED AUTOS 6 6 ❑ UMBRELLA LIAR ❑ OCCUR EACH OCCURRENCE 6 ❑ERCEBS LIAB CLAIMS MADE AGGREGATE S nIHDOCTIBLE 6 RETENTION $ 6 WORKERS COMPENSATION ® x STQO- 07H- AND EMPLOYEES LIABILITY TDg LffiT' ER EACH ACCIDENT 6 100,000 THE PROPRIETOR/PARTNERS/E.L. A EXECUTIVE OFFICERS ARE ❑ incl ® excl 601159301201002/10/2010 02/10/2011 E.L. DISEASE - EA EHPLOYBE 6 500,000 B.L. DISEASE - EAE I—. 6 100,000 COMMENTS DESCRIPTION OF OPERATIONS OR LOCATIONS: DAVID MISPILKIN IS NOT COVERED BY THE WORKERS' COMPENSATION POLICY CERTIFICATE HOLDER CANCELLATION MARIANNE SCARANGELO saoazn ANY of THE naoaE DESCRIBED eoLlclEs BE CANCELLED BEFORE TSE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITS THE 271 CANDLESTICK RD POLICY PROVISIONS. N ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE •• The Commonwealth of Massachusetts Department o f fndust.ial Accidents Office of investigations 600 Washington Street Bostorz, A,1A 02III www•masS-gov/dia Workers' Compensation Insurance Affidavit: guilders/Contractors/Electric mians/Piumbers oi ant Information NameIt (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor 2. ❑employees (full and/or part-time).* 1 and I have hired the sub -contractors 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. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation 3. ❑required.] I am a homeowner doing all and its officers have exercised their work Myself (No workers' comp. right Of exemptionper MGL c. 152, § I (4), and have insurance required] t we no employees- [No workers' comp. insurance required.] -Mt that checks box Al must w3U 121: uut `.he section --i-o ' Idomeowners who submit this affida ' Ehavr2r^ + Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions .1 LO Plumbing repairs or additions 12.[] Roof repairs 13.�.pther&ov0 vtt shed an a they nal doing al; wing and then hire outside contactors dust submit a new affidavit indicating such. !Contractors that check this box muni attached an additional sheet showinP the name of the sub -contractors and their workers' rn __— I am an employer that is providing workers' information. compensation irzsurance for my employees. Insurance Company Below is the policy and job site Policy # or Self -ins. Lic. #:/� 1 a r� Q `L Expiration Date: p Job Site Address:l Attach a copy of the workers' compensatiAIA on policy declaration etre (showingCity/State/Zip: Failure to secure coverage as required under Section 25A of MGL C. 152canltothe pohcy number and expiration date). position of fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form othe f a STOP WORK ORDER and a fine criminal penalties of a 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. 1 do herebyentity under t/he pains and penalties of perjury tiirit the information provided above is true and correct r Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/I,icense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. Cit3'/Town 6. Other Clerk 4. Electrical Inspector S. Plumbin, Inspector Contac: Person: Phone r: Information an- d 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 peon 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 apartnz ents 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 be cause 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 coxnpfiance 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 instance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners,. are not required to carry workers' comp enation 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 siure to sign and date the affidavit. The affidavit should be returned to the City or town that the application for the perriiit or license :S being requested, not f.'.^.e DepaT—me !t 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-incirance 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/liceme 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 Office oflnvestigations would like to than 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 W a:shmgton Street Boston, MA 02111 Tel. m 617-72.7-4900 ext 406 or 1-8 77-M4SSAFE Revised 5-26-05 Fai 114,617-727-7/749 )Arvrv7.mass.. aov/dia. TV tt br%d stt tt for hot Sutmmer fu.w! ;i S too V-A ! 11117 •'� ik�;�� S, orf ��`� fa 12'(3. % m 1�5' (4.57 m) 12' x 23 (3.66 M x 7.01 m. 1 18'(5.19 m 2ll n.) 15'x 26'(4.57 m x 7.92 m) OYd WI(}l X24' (7:32 m 27 (� �3r� ® 15' x 30' (4.57 m x 9.14 m) I(1VISIbl2 SitppQRS � .14", m ,n 18' x 331(5.49 m x 10.16 m) ry M 550 on TM H -&'W stl Le for hot summer fkvO Structure 8 -inch resin top ledge 6 -inch fully supportive steel uprights Synpror"' resin decorator ledge cover and base crown: I -Won't chip, peel or splinter - Tie-in support to the upright # for greater rigidity - Flush design eliminates exposed screws _ • Bottom wall channel made in resin Bottom joiner plate with integrated base crown made in resin Yard Eutender System _ Our ova! pools come with the E'k Yard Extender System, a series of practically invisible lateral supports that you place in the ground ii+yll;. 7:.1 i it corrugation I , ' 275, j - guard- 99.S% pure A rippled finish lets the wall resist both C Alkaline cleaned Q O D Bonderized { water pressure and external shocks j` yr i i If I • � j �. ' i'r Q G Synpro- I # \ �� H Pre -finished quality steel core Walt poin't ,' t Polyenamel'"' Kote J © � r � it Duoguardr"' Computer -designed wall joint ensures better to resistance water pressure ID YEARS Wall reinforced with steel bars Pre -finished pool components All metal parts are coated and finished oversized bolts augment stability h I 'Depending on the machine used for production, your wall will be shipped with one of the two pictured wall joint designs - Protective Finishes ZincguardT"" 275 hot -dipped galvanized Zinc coating on both sides of the steel for maximum protection against corrosion Polyenamelr"" Kote Excellent tried-and-true finish for a long-lasting pool Resin -shield - Textured resin coating applied to the outer face Synprom Non -corrosive resin that contains UV stabilizers that protect against discoloration and chemicals DuoguardTm An epoxy and alkyd resin compound that protects against condensation between the wall and the liner Water Safety Pool -fit System _Y Parts are pre -grooved for fast and easy installation of screws _! Unique design locks screws j 111 solidly in place for long-lasting structural integrity r • �Y 1 A Galvanization B Inc The purchase of an aboveground pool providesyears of pleasure and fun, but it also involves water safety. Although we cannot supply a full-time lifeguard, we strongly recommend thatyou implement the following safety rules. These will help provide a pleasant atmosphere foryou andyour family. • NEVER jump or dive in an aboveground pool. • Maintain constant adult supervision when children are in or near any body of water. • Read all of the safety. installation, and maintenance information contained In the instruction manual and Water Safety brochure beforeyou start installingyour pool. • Askyour city about any specific rules and regulations that apply to aboveground pools. • Follow the instruction manual and maintenance instructions. • Never remove applied or posted safety stickers or signs from your pool or pool area. • Barriers to prevent unsupervised access, especially byyoung children, should be built. installed and checked on a regular basis to ensure they are in good working order. • Inspect your pool, barriers, alarms, and other related equipment on a regular basis in order to ensure they are in good working order and that they are safe. The installation, maintenance and safety manual contains detailed tips and recommendations. They must be read, followed and applied on a regular basis, as they will prevent unnecessary accidents and will ensure many summers of pleasant, safe family fun. SWIM SAFELY AND STAY SAFE Printed in Canada.The dimensions, weights, illustrations and other specifications are approximate. The company reserves the right to modify and/or discontinue without notification any feature in any pool model. 0 Copyright 2007 M 0 0 CO 275, j - guard- 99.S% pure C Alkaline cleaned Q O D Bonderized { E Chromic rinse F Resin-shieldTM O._t i'r Q G Synpro- # \ �� H Pre -finished quality steel core ©. Q 1 t Polyenamel'"' Kote J © � r � it Duoguardr"' ID YEARS Pre -finished pool components All metal parts are coated and finished before assembly for longer -lasting effects _ The purchase of an aboveground pool providesyears of pleasure and fun, but it also involves water safety. Although we cannot supply a full-time lifeguard, we strongly recommend thatyou implement the following safety rules. These will help provide a pleasant atmosphere foryou andyour family. • NEVER jump or dive in an aboveground pool. • Maintain constant adult supervision when children are in or near any body of water. • Read all of the safety. installation, and maintenance information contained In the instruction manual and Water Safety brochure beforeyou start installingyour pool. • Askyour city about any specific rules and regulations that apply to aboveground pools. • Follow the instruction manual and maintenance instructions. • Never remove applied or posted safety stickers or signs from your pool or pool area. • Barriers to prevent unsupervised access, especially byyoung children, should be built. installed and checked on a regular basis to ensure they are in good working order. • Inspect your pool, barriers, alarms, and other related equipment on a regular basis in order to ensure they are in good working order and that they are safe. The installation, maintenance and safety manual contains detailed tips and recommendations. They must be read, followed and applied on a regular basis, as they will prevent unnecessary accidents and will ensure many summers of pleasant, safe family fun. SWIM SAFELY AND STAY SAFE Printed in Canada.The dimensions, weights, illustrations and other specifications are approximate. The company reserves the right to modify and/or discontinue without notification any feature in any pool model. 0 Copyright 2007 M 0 0 CO i i " a�iJ� /�D M ��aSp� �� /. r- --_, .. �_