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HomeMy WebLinkAboutBuilding Permit #712 - 39 SPRING HILL ROAD 4/6/2012TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Z' Date Received Z 2c�t Z Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION 32 s� n m * t (_ /� IU � rf� A-vldN 0 Print PROPERTY OWNER eam J 60 Unit # Prin MAP N0: LO A PARCEL:QZONING DISTRICT: Historic District yes <ZFQ.)- Machine Shop Village yes MD 100 year-old structure yes "-% 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 ralt�t�, ® Septi + oocip a �n w� . J r oOWa ershed s ct: M ater/S wer + OWNER: Name: Address: CONTRACTOR] Address: -� 0 LrJak-turIWIN ur wuxx iv ter; (Identification Please Type or Print Clearly) r P02-41 „,C � ? S ��E- 33?� .5-21S-2- Supervisor's '3SZ Supervisor's Construction License: CQ l 0 31(D )Exp. Date: 0-1 Home Improvement License: l (Q 20 Exp. Date: 02- - (3- f 3 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $92.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ _S �, ©OZD FEE: $ c- Check No.: � , ,� Receipt No.: 'V11 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund _ Sidnature;of;contractort .Ih.. Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Art ❑ Swimming Pools ElTanning/MassageBody 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 PLANNING & DEVELOPMENT COMMENTS J CONSERVATION COMMENTS Reviewed o DATE REJECTED RE HEALTH Reviewed COMMENTS <7D ._ / a n' DATE APPROVED A' Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes 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 on site Located at 124 Main Street Fire Department signature/date COMMENTS yes no 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 servicedroprequires approval of Electrical Inspector Yes DANGER ZONE LITERATURE: Yes No MGL Chapter 166 section 21A —F and G min.$10041000 fine Doc:.Building Permit Revised 20117une/mi 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 o Photo Copy of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition or Decks o Building Permit Application ❑ Certified Surveyed .Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkl6r Plan And Hydraulic Calculations (If Applicable) o 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 o Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract o Mass check Energy Compliance Report o 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 Doe: Doc.Building Permit Revised 2008mi r Date ......./...'.. TOWN OF NORTH ANDOVER PERMIT FOR WIRING L�7 This certifies that ............. ........... .........' .................. ................:........ has permission to perform ........ wiring in the building of 5CD .............................................................................. at ..... 5.! K!......l...� C . C ... ............. _, orth Andover, Mass. Fee ... ��-r' Lic. No...1.3 J ...... Z ....... ............. . . .. .. ... ...... 1, ELECTRICAL INSPECTOR [j Check # T7 2 0 i r. 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule g: In accordance -with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be urgonn throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of.ongoing construction activity, and may be.deemed.by the -Inspector-of-Wires abandoned-and_invalidif he—_ .. _ or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entitystated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this puipose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending"through August 15, 2012. Mule 8 — Permit/Date Closed: 2 Note: Reapply for new per 0 Permit Extension Act — Permit/Pate _ Closed: Commonwealth of Massachusetts Official Use Only a , Department of Fire Servlces Permit No. /6 2 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (leave blank)' APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code WC), 52Y CMR ,1r2.0 (PLEASE PRINT.ININKORTYPE-4LLINFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned ives notice of his or her intqntion to perform,he electrical work described below. Location (Street & Number) rl n Owner or Tenant ¢7 ,s Owner's Address Telephone No. 010" 25"r-2 Is this permit in conjunctionwith a �bu`ilding permit? Yes Y No ❑ (Check Appropriate Box) Purpose of Building /��Sf'We'1Ce Utility Authorization No. Existing Service Amps / Volts OverheadEl Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity ` Location and Nature of Proposed Electrical Work: Com letion o the ollowin table m be waived hy the Inspector of Wires. Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA Luminaire Outlets No. of Hot Tubs Generators KVA Luminaires Swimming Pool Above ❑ In- rnd, rnd. o. o mergency Lighting Satter Units Receptacle Outlets No. of Oil Burners FIRE ALARMS No, of hones [I'D Switches No. of Gas Burners No. of Detection and Devices anges TotaInitiatin No. of Air Cond. Tonsl No. of Alerting Devices aste Disposers Heat Pump Number _Tons KW No. of Self -Contained Detection/Alertin Devices ishwashers Space/Area Heating KW Local ❑ Municipal ❑ other Connection ryers No. of Watero. Heaters KW Heating Appliances KW No. Si Bal as Si s Ballasts Security Systems No. of Devices or Equivalent Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail ifdeA ed,, or as required by the Inspector of Wires. Estimated Value of Electricalork: (When required by municipal policy.) Work to Start: G%G -/vim Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE :COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such c�ov,Jer 4a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE Id BOND ❑ OTHER ❑ (Specify:) I certify, under thenains ad pen tips ofperj ,ry, thn_t the '. ortnatior. on this Application is true and coop; etia FIRM NAME: o •' ski zo� /` G LIC. NO.: Licensee: 121 �Qc" C Signature LTC. NO.: (Ifapplicab e, enter "exem t" ie license num erline.) Bus. Tel. No.- De' "ba Address: / ` S , Qf d' Alt. Tel. *Per M.G.L c. 147, s. 57-61, security work requires Dep rtment ofPublic Safety "S" License: Lie. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's a Aent, Owner/Agent Signature Telephone No. PERMIT FEE: $ r ._ • �JUJL'(�UdJ.`►J.'LF��.(�••-T�-.t J(�C{•�y:.L�.If.%LiJt..�l. 1�l•�®��'F�j �'i [� �iJ,[ �`U,Y.,I,���J. �,+.�.J4� � • _ Ee ..••V.�.�V.L1.7 �JG.L:fV�®.L0. `�S~ • .. ._ r. ' �� + 2. J�'12VA1Gl�la�'�C'7[`IOI'7; . JPasse$--[ } Vailetl--j}e-zus�eetiox�xecuixeci($50.00}- [ hVectors' Comments: ft4edors' ftnature -• rto initials) Date 3, TJie7J)D+R+COTJND xNUCTZOW: Dassed-- Z ecl-- j ]e inspecfior�xequirecl ($50.00) [ Inspectors' comments: Chs.pectors' Signature -).o initials) ))ate 4. WSpXcTTOZ+I"•--SER'Vjc%: -D NAME ONAL G KIM: Passed — f +'ailed - [ !fie-5nspeedo' n required ($50.00) - xnspectbrs' coxnmenfs: (Zizspectors' signature Jao jnitials) Date �. D��EC'�T'ZO�1'-• dila: asp ectors' coy stems: • 9 ' DOOR TAGS "E+ TO BE EIEEED OUT.AND J EFT OST SITE F TBS .AREA TO BE II VECT ED is NOT .A.CCE981BIF, AND .A, RE WODECTION OF 550,0 DIM TO -13F, CMR.GED. - .'�sset�s [+'aflefl�jxnspectiou requirecY($50.00) - X j uspectors' co7avxte�ifs: ® v •2 -, L it • (Xuspeefore Signature •• 3ao Wiials) Date 2. J�'12VA1Gl�la�'�C'7[`IOI'7; . JPasse$--[ } Vailetl--j}e-zus�eetiox�xecuixeci($50.00}- [ hVectors' Comments: ft4edors' ftnature -• rto initials) Date 3, TJie7J)D+R+COTJND xNUCTZOW: Dassed-- Z ecl-- j ]e inspecfior�xequirecl ($50.00) [ Inspectors' comments: Chs.pectors' Signature -).o initials) ))ate 4. WSpXcTTOZ+I"•--SER'Vjc%: -D NAME ONAL G KIM: Passed — f +'ailed - [ !fie-5nspeedo' n required ($50.00) - xnspectbrs' coxnmenfs: (Zizspectors' signature Jao jnitials) Date �. D��EC'�T'ZO�1'-• dila: asp ectors' coy stems: • 9 ' DOOR TAGS "E+ TO BE EIEEED OUT.AND J EFT OST SITE F TBS .AREA TO BE II VECT ED is NOT .A.CCE981BIF, AND .A, RE WODECTION OF 550,0 DIM TO -13F, CMR.GED. - I The Commonwealth of Massachusetts DZ Department of IndustriqlAccidints Office of Investigations IN 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/tndividual): Address: 1'5� �1;7 City/State/Zip: � l/� �� ��r/ Phone #: f/—/F— 39"3 " 3-F?5-� Are yo n employer? Check the appropriate box: EXam 4. ❑ I am a contractor and I Type of pro'ect (required): 1. a employer with general 6. ew construction employees (full and/or pa -time).* have hired the sub -contractors ?• Remodeling 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have 8. ❑ Demolition workingfor me in an capacity. Y p tY• workers' comp. insurance. 5. ❑ We are a corporation and its 9. E] Building addition [No workers' comp. insurance 10.❑Electrical repairs or additions required.] officers have exercised their 3111 am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] t employees. [No workers' 13.❑Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:, Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: ` l / City/State/Zip://V1*/A/I Attach a copy of the workers compen tion policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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. Ido hereby certi under t 'pa' andpenalties ofrjury that the information provided above is true and correct. Signature: Date: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or. written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint 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, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic 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 bum 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:MASSAFB Revised 5-26-05 Fax # 617-727-7749 wwwanass,govfdja. O °o co v a 0 Eo 2 a4 C7 w 00 G o o a 0 04 a o G 0. V Ow w a w o w cn . w a P4 o u: w" w v oR z Cl) o 0 cn zCL C C : m C C v o � N CC'' O O �I v C.3 ;. •p.E O m C = O O � H vr!1 E a J L 0 COL �... C f moo= 0 O u cn �O me l 4CL= E L � N Ma h3 (j) cm ca C H F-1 = O O W y UL � .00 ca 0 a C/)c cm(/� c W �eoa a�_ W :Q 40 U.h O . L l o •«- c, c 4 s Q 0 Cb c -o c o = m o-G--LAJ o N Vi ea =_ LL � � �•" C w••. O ui � •fq •dZ O C Z r u •E ci 10 w •y o C ID CL. :, g . h m� O� Z F•- . s $ o. w m 1T I 4-4 a 2 0 L V Z co C. O y D C Ww` � cm I O �y CD CD m m L- H— _ CL 4-0 CD 3� CD CD L e_�v o a a- cmQ c 0 ca C v J .� FL O CD W Z m 0 CL v vs � C C _cc C. h D U) N ce W W W N w LOT 20-A PLAN NO. 10388 SB/DH FND PLOT PLAN LOT 18-A LOT 6 SHOWING PROPOSED POOL LOCATION S49°49'34"E IN 77.29' NORTH ANDOVER, MA 39 SPRING HILL ROAD 0 30' 60' 90' SCALE: 1" = 30'-0" POOL DECK 47'+ POOL TOI1 J �LI/�E �1 320.00' N 490 32'38" E 56.9' SEPTIC TANK - TO POOL DISTANCE = 78'± 45.3 o MARCH 1, 2012 % co D & A SURVEY ASSOCIATES, INC. LOT 21-A o P.O. BOX 621 MEDFORD, MA 02155 A - 43,560 S.F. "' (781) 324 - 9566 (781) 321 - 2501 (FAX) 1.00 AC. +POOL TO I azo1 LOTT L� A20' PROPOSED6' FENCE TO SURROUND POOL SCR. 5 r POR. 2 STY. NO. 39 SEPTIC p TANK 80.00' N 490 32'38" E SPRING HILL LOT 5 N s 0 •mss o0 Vq Y� CIO Q 1 SB/DH 1 1 FND R = 595.10' L = 145.41' 0 = 140 00' 00„ (PUBLIC - 50.0' WIDE) RECORD OWNER: MARK AND SANDRA BOSCO DEED RECORDED IN BOOK 12724 PG. 189 PLAN REFERENCE: PLAN NO. 10388 LOT 4 LOT 3 'A OF ;mL LAW10 Information and Instructions - Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint 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 fhe occupant of the - ; , dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and 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 W shingtoR Street Boston, MA 02111 Tei. # 617-727-4.900 oxt 406 or 1-877,7MASS.A.EE Revised 5-26-05 Fax # 617,727,7749 www.Mass,govldia 4 The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations kvi 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le;sibly Name (Business/Organization/Individual): Address: -70 SID ' o fry.s City/State/Zip:Phone #: p o a % Are you an employer? Check the appropriate box: Type of project (required): 1. &am a employer with 4. ❑ I am a general contractor and I 6. E�New construction employees (full and/or part-time).* 2. El am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. E] Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g E] Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. t c. 152, § 1(4), and we have no employees. [No workers' 12. ❑ Roof repairs " A J+�D�Kd' insurance required.] 13.[J Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they ate 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. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:'_ `1 A 3,;Js, Cii-� Policy # or Self -ins. Lie. #: ( L 3 2-1 �_7 6 Z Y_ Expiration Date: (Z ' 311 12— � Job Site Address:_31 n ' GC° City/State/Zip: Attach a copy of the workercompensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby ceyWunder thepajns anftenalties ofperjury that the information pro videdabove is true and correct. n Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License 2-1 V LAZ,, V- 001'2— Official 012 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone #: :Eileen P, Hart, RRI -HLb International New Engl To:3 Cols & reds: No Ando & (2) No Read 08:29 03/20/12 EST P9 6-3 A &H..,,.HA• 99CA'l CAUII votIAI It .w-' ACORDT. CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 3/2012012 THIS CERTIFICATE 13 ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. TMIS CERTIFICATE OF INSURANCE- DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is art ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS VIIAIVED, subject to the terms and conditions of the policy, cerlaln policies may require an endorsement. A statement on this certificate does not confer rights to the certlllcato holder In Ileu of such endorsoment(s). PRODUCER HUS Intembtional New England 299 Ballardvale St Wilmington, PAA. 01887 978 657-5100 CONTACT NAME: _ PHONE978 657-5100 -475-7939 'A1C. No EII: A, C, NoS: E MAIL ADDReSS: INSURER(S) AFFORDING COVERAGE � NAIC C Nautilus fns Co T t INSURER A: -j-- INSURED Family Pools & Patios Inc. INSURER 8: Technology Insurance CO INSURER C: Acadia Insurance Company 31325 ' PERSONAL �, ADV INJURY 31 000 000 INSURER D: Safety Insurance CO 70 S. Broadway Lawrence, MA 01843 ,NSURER E : ENSURER F rnvFRAnxG r•FRTIFICATF NUMF.FR' h1:V15IUN NumbtK: THIS IS TO CERTIF, THAT THE PDI -CIES OF INSURANCE LISTED SELGW HAV-" BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLEIIYPERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT CR OTHER O=UMENT WITH, RESPECT -0 WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALI- THE TERMS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED EY PAID CLAIMS. _ 1' 8 LTR TYPE OF INSURANCE L N U VD _ POLICY NUMBER FO IC P MM/DD1'rYYY PCLICY EMP L[M TS IMtS7DDYYYY _ A D GENERAL LIABIUTY X CG_,?.hfl'ERCIAL GENERAL LABILITY CLAIMS MADE X OCCJR X BVPD Ded: $2.500 NN138379 3947232 --- D9,I1912011 213112011 0.411.911201. 12131/201 EACH i,CURRENfE 131 300,000 AP-0�C�� 7J P.ENTED / � REF,1:.G�Efl •.'CCllflE'1.? $11)0;00G MED EXP (Any Era paren;,l $5,000 ' PERSONAL �, ADV INJURY 31 000 000 GENERAL AGGREGATE 32,000,000 GE.NTLAGGRE',ATE IyUVF APPPII'!!E1S 'ZER' PO-IK,Y JfCT I LOC AUTOMOBILE LIABILITY ANY AUTO ALLL1N'NED I qX WHEGULEDAUTOS AUTOS H:REV ALIT02 AUTOS CS. CJtsPn�P'.GG 12,000,000 P' ROL+U' $ -- E,r',_ "c, E` T �100G00D BODILY INJURY (Per re son) S OPEERT' DkNIAQEX (Fe' hccK1r ent UMBRELLA LIAP ! Ua EXCESS LIAO G1-A1MS-%1ADE EACH xcURRENCE 4 — ! AGGREGATE $ DED I RETENTION'S $ 03 I WORKERS COMPE.0ATION AND EIAPLQYERS'L!A.BILITY Y/N ANY P?OPRIETORI?AR'. N-PtEXECUTI+: E OFF+CEWLIEMEEREXCLUDEG? (Mandalory In NHI I yes, oescrl-be undar DESCRIPTION OF OPERATiON5 LxIUK• NIA _ T WC3297825 2131!2011 i 121311201 4,W �TATL- OTH- ; I E L. EACH ACCIDENT $500,0011 YEE $500,000 .. ISEASE - POLICY LMII- $500,000 ELD C Property CFAr318008415 911912011 091191201- vrs limits I ! I I DESCRIPTION OF OPERATIONS !LOCATIONS r VEHICLES ;Attach ACORD 101, Additicn;l Rernarka Schedule, If morn space Is. -Squired) re: Mark & Sandy Bosco, 39 Spring Hill Rd.. Town Of North AndoverSHOULD ANY OF THE ABOVE DESCRIBED POLICIES 3E CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE Vi LL BE DELIVERED IN 120 Main S1 ACCORDANCE VRTH THE INYJCY PROVISIONS. North Andover, PAA 01845 AUTHORIZED REPRESENTATIVE J� C400—"' C 1968-1010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) 1 of 1 The ACORD name and logo ars registered marks of ACORD #5697691111624304 EH002 <. ✓S`LG �0�7?7/I??r271%ft/C'CLLLsL O� il•(.QQJC%fc Z£C6G✓••G Offs., of Consumer Affairs & Business Regulation ROME IMPROVEMENT CONTRACTOR Registratiom 118204 TY 9 �:� - • �---� h�� Expiration,- 2/93/2013 Private Cosporatia FAMILY POOLS & PATIOS INC. WILLIAM GIANOPOUWS 70 S_ BROADWAY LAWRENCE, MA 01.843 Undersecretary ii1fi��Yi� - 1 i Ali m:�M;e4 it .disi3a,� } o �S 1D33D .: �a Pd ULOS WILLIAM G AY 70 S BRoXDW O1.943 E.ct LAWR 7119t2013 20968 <. ✓S`LG �0�7?7/I??r271%ft/C'CLLLsL O� il•(.QQJC%fc Z£C6G✓••G Offs., of Consumer Affairs & Business Regulation ROME IMPROVEMENT CONTRACTOR Registratiom 118204 TY 9 �:� - • �---� h�� Expiration,- 2/93/2013 Private Cosporatia FAMILY POOLS & PATIOS INC. WILLIAM GIANOPOUWS 70 S_ BROADWAY LAWRENCE, MA 01.843 Undersecretary m �IU9 a is 'r w� V providing a full line of services and supplies fully licensed and insured www.familypoolsonline.com Name MA, --y- + h &D GO __ Date 15 20 t 2 Address _1-Dy2)L14 I U 12.1 City A -P1 J'v­- State Ike-, Zip ( Home Phone _ Work Phone Cell 574-90- Add'I# I�t.•x Cross Street/Directions 0-0, ' Estimated Start Date Estimated Completion Date We propose to furnish and install one egunite I-0 X 42 Z` Swimming pool for the sum of $ Z!;� 000 11, �&--d l f,,,.9 --4e - --, THIS PRICE INCLUDES: Normal Excavation up to 8 hours on day of dig Backfill and Sub -Grade up to 3 hours Underwater White Light 120 Volt Steel Reinforcing per Engineered Plans for gunite Steel Structure per Engineered Plans for vinyl Over -Flo Line for added protection Pressure testing of plumbing during construction Ten Year Plumbing Guarantee (see specifications) Transferable Lifemne Structural Warranty Manual vacuum cleaner kit 3 -Step stainless ladder Rope and Floats Initial balancing chemicals 8 to 12 Wk supply of maintenance chemicals (supply depends on pool size) Leaf net Wall brush Extension pole Waterline Tile (6') ' Liner Choice Test Kit Surface skimmer (s) Z Dual Main Dr s Coping Steps%Se ,,.`-fes Handrails Filter (plumbed no more than 25ft from pod) Pump & motor_ THIS PRICE DOES NOT INCLUDE: Any plumbing over 25ft from pool. Additional runs are not recommended but would be at a cost of $ _-_�S per foot per line. Machine time in excess of that specified above. Additional machine time to be billed at $ 1 to !r including machine, operator, and laborer, due with second pool payment. All hours of trucking will be charged at $ 4-0— per hour per truck due with second pool payment. Any dumping costs incurred for disposal of ledge, large rocks, garbage, stumps buried or otherwise, building materials, unsuitable or nonstructural soils, or any unforeseen material that must be removed. Removal of ledge or large rocks by way of a Starr bit, chipper, or blasting. Additional fill, if necessary, for proper ball or reshaping of hole, supply or spreading of loam, reseeding of grass. Patio, fence, retaining wall, or any accessory items other than noted on contract Electrical wiring, fuel connections, heater venting, fuel storage tanks or permits. Repair or replacement of sprinkler systems or any buried items such as well lines, drywells, leach fields, electrical lines, cables, etc. that are damaged during construction costs due to water or soil conditions (ex. clay, peat, live sand, excessive rock, etc.) requiring a stone pack of the hole. The stone pack will be at an extra charge of $ _.4 t� minimum to $ _4_) maximum and at the discretion of the job supervisor. Additional machine time and/or materials necessary to rectify such a condition will be at a cost over and above the stone pack and will be quoted by the job supervisor. Water to fill pool. Initials CUSTOMERS MUST SUPPLY: • Access for all trucks and equipment • Building and Electrical Permits or assume the costs necessary to obtain such permits. • Water and electric necessary for construction of pool Customer must water cure Gunite shell for 7 to 10 days if applicable. • Watar to fill nnnl immxlintely unon interior finish NOTES OPTIONS. t $ �� b6-�� Diving Board y `� Solar Cover Additional Pool Lighting '>t (� ) HeatereoV(– Environpool Plus, 8 hd+2 surface– Additional Floor Heads ( ) Polaris Vac -Sweep Polaris retrofit only— .c Bench iZ�� Interior Finish Spa ( ) Automated Control System ( ) r Salt Chlorine Generator ( m(3 p - Other PAYMENTS: 113 EXCAVATION TOTALS: Basic Pool Price Options SUBTOTAL (p,2.5%Sales Tax iqo TOTAL It ((�J/`('`,'f •` Less 10°116 Deposit E_Rr Balance of Contract 113 BACKFILL + EXTRAS 113 SYSTEM START-UP The buyer hereby agrees to pay, in full, the total amount of this transaction upon start-up of the installed pool. Your salesman or job supervisor will meet with you prior to.excavation at which time all decisions including pool size, shape, elevation, liner print, and all options must be final. Changes after this date will be subject to extra charges, where applicable, and will result in unavoidable delays. You, the Buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. Credit card payments not accepted on contract amount. �! (� Z2r►� t^ BUYER date SELLE L& date 40 r _Z—CO•BUYER date i Location - % No. Date / --- j Check #54a: 25162 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $�53,1Z- Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ' 1 Building Inspector