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HomeMy WebLinkAboutBuilding Permit #1003 - 58 MOLLY TOWNE ROAD 6/3/2015 111 - L NORTH BUILDING PERMIT 0` [Ur" 16;x% TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 7D Permit No#: ®Q Date Received rJ � gSSACHUs�� Date Issued: 7! ' IMPORTANT: Applicant must complete all items on this page LOCATION � o��� RJ Print PROPERTY OWNER et arl Print 100 Year Structure yes MAP OIo5 PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential )(New Building KOne family Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: i _❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Waters hed'District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: 1 l.1 Y til r�ier Identification- Please Type or Print Clearly OWNER: Name: egg . Phone: 7 - S/3-- ` / Address: I+ ti�;� J-4ydive f il 01 ,9 �s Contractor Name: ?Q01260'11 I 9"tw-s) Phone: - Email: (eno w+J1,/) A e Li cavv\ 77.0 Address: ��� r, (b AJ i6� kc1 LJ re vu". dV',k, 01 ,R43 Supervisor's Construction License: © 10. 35 Exp. Date: 40 Home Improvement License: S Exp. Date: 62.- /.! - / 7 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: $ ' 31 FEE: $ 32 Check No.: 651,� Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund r Plans Submitted Plans Waived ❑ Certified Plot Planf�' Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swi ruing Pools Well `❑ ❑ o k3/0 `� Tobacco Sales Food Packaging/Sales ❑ Private(septic tank,etc. Pennanent Dempster on Site ❑ dy-) , 'ieV'j&/ \ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature #kz,�_�__ COMMENTS r I CONSERVATION Reviewed onSi 1,Sj / Si nature (WA, COMMENTS l9 s� �n C_n>` _exr� HEALTH Reviewed on i Si natu r COMMENTS /L Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments ci'onservation Decision: Comments Water& Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE D a `- -. - _ Located 384 Osgood Street i � EPAR+T�MEN�T' temp Dumpste� oriitsifer eyes F 11, E; : eDepatmentsignature/dafe LE, CS—_ _ T - - Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANCER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) 211'' Izs < w�„-� �� I ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Building Permit Application Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract 4, Floor Plan Or Proposed Interior Work 4 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 :aF Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract # 2012 IECC Energy code 4. Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 Location �8 ! '`"� led No. / d 11 3 S Date . • TOWN OF NORTH ANDOVER • s�;l'�L'LD 764 � • Certificate of Occupancy $ Building/Frame Permit Fee $ 532 — Foundation 5.32 — Foundation Permit Fee $ a Other Permit Fee $ , , TOTAL $ f� Check# r 9 4- 1 Building Inspector NORTH Town of 1 EAndover No. /6a 3— /so soh ver, Mass, �o COCNICNl WICK �d ADRATED S U BOARD OF HEALTH PER IT L D Food/Kitchen Septic System THIS CERTIFIES THAT A.S.A.94A .....FNA.r . .. .................................................. BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on ......>� �. .�:!'� '..."... ....... . .. . .... .. .. �/ Rough to be occupied as .cao ..�ss.Av...... .�... (4&V?, ......0.1b t...................................... Chimney provided that the person accepting this permit shell in eve respect conform to the terms of the application Final p p p g p every on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI TA Rough Service ..................... ........................................................ Fina BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. STEEL WALL POOL SYSTEM 20' X 36' FIGURE 8 DWG#: GS-1105 1 DATE: 2/21/2008 REV: B PAGE 2 OF 3 TURNBUCKLE BRACE 8'-0" ST-720101 R Ix31 2' ST-720101R *� STEEL PoOL PANEL ......ffffff TURNBUCKLE PIECE ANGLE-RACE 4, 0„ $T-720101 R CONCRETE FOOTER z'POOL OEAOMAN BASE PLATE R10'-0" 1 1.t ILI STAKE EMBEDDED NUT BRACE 12'-0" 20'-0" all R6'-0" MUDDED N STEEL POOL PANEL I CONCRETE FOOTER EASE 4'-0" ST-720101 R ASE BRACES AND DECK SUPPORTS ST-7 20101 R `�12+14)I I li i11 SFAAE AT PANEL JOINTS AS SHOWN ST-72010111 DECK SUPPORT(OPTIONAL) —..... F 3'-4" 4'-0" 6'-0"--• - -Aid`; i AMIN Sh DANGER:DIVING MAY Alpha DOCUMENT IS FOR ILLUSTRATIVE PURPOSES ONLY. - Alpha 3 Mfg.makes only those representations which are stated in Its written warranty.Any other representations,statements,or contracts mntw by the Etrxtat/itinttitHtll RESULT IN SERIOUS attributable to the dealer/contractor only.The dealer or contractor who sells or Installs your pool is an Independant contractor and Is not na nllnnt Lw xngd41vQ4'it Atphit j, NU VINU INJURY OR DEATH. to normal ground conditions.There may be additional precautions and/or methods of construction.The responsibility Is the contractor's. A snfnty IInN,Willi INuIW,If Hi Hi Signage must be permanently attached around the change.-Different methods and precautions may be dictated by various ground conditions.This is to be determined by and Is the rmporisiblllty of thx 1111111141#1101 Willi IN u, be done in accordance with all federal.state and local buildino codes.as well as A.N.S.I./N S.P.I.sunnested standards HOrMM SPH:IFICA t It INS MI Pit Riti,r t ut i vt,nt i PAGE 2 OF 3 36'-2 1/8" 8 0 ST-720101R 3'-4" ST-720101R ST-240100R ST-24006ORR ST-36008OR ST-48008OR 4'-0" ST-720101R ST-72006ORR 0'- 7/8" ST-720081 R R10'-0" R6'-0" N N \ P _ h m O m 12'-0" 20'-O" i 1 2-0" YP ST-720101 RL — — — — — FS-9694RBW' R6'-0" R6'-0"— R8'-0" 4'-0" 0'- 7/8" ST-720101R ST-720081R 171 ST-72006ORR BRACES AND DECK SUPPORTS ST-720101 R ST-24010OR ST-36008OR ST-48008OR AT PANEL JOINTS AS SHOWN ST-720101 R ST-240060RR 3'-4" 3'-4" 8'-0" 1 4'-0" —6'-0"—• 14'-0„ 12'-2 1/8" F DOCUMENT IS FOR ILLUSTRATIVE PURPOSES ONLY. a 3 Mfg.makes only those representationswhich are stated In Its written warranty.Any other representations,statements,or contracts made by the dealer/contractor to the customer regarding any components produced b AIutable to the dealer/contractor only.The dealer or contractor who sells or installs your pool is an independent contractor and is not an agent or employee of Alpha 3.The construction methods illustrated here are surmal ground conditions.There may be additional precautions and/or methods of construction.The responsibility is the contractor's. a safety line,with buoys, Y Alpha 3 are change.-Different methods and precautions may be dictated precaution various ground conditions.This is to be determined by and is the responsibility of the contractor who is not eragent ofthe suggestions o i and apply only be done in accordance with all federal,state and local building codes,as well as A.N.S.I./N.S.P.I.suggested standards.-BOTTOM SPECIFICATIONS MUST MEET OR EXCEED A.N.S.I/N.S.P,l/AP S.P RECOMMENDED-0"to the shallow TSTA de f the point of first slope slgriage must be permanently attached to the entire perimeter of the pool.See instructions with signage.-IT IS NOT RECOMMENDED TO USE DIVING AND/OR SLIDING EQUIPMENT ONRESIDENTIALPOOLScomponent parts.-Installation is to STANDARDS=NO DIVING' �n��la.Po i North Andover MIMAP May 27, 2015 Ay •+ASF :. '- `t 1VL k 4 f 39 ;1 e� y/ X t ." W- IKIV 4' C s .. r 7 �t,,`1•, •' .�.7r" 'r'{' '''.}Y '`_Y +" ,,3' }3 , ,r Sy,,•t;� I. •�. ,..' `=l �.;�)f+'�.3./e�; .may.,;•��. y r`'� IIIA• � Y ��+ � .. •11 't. `L Interstates —I —SR Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, Roads Meters Data Sources:The data for this map was produced by Merrimack t Easements f AORTN 4 Valley Planning Commission(MVPC)using data provided by the Town of O tilt o �. North Andover.Additional data provided by the Executive Office of ❑MVPC Boundary ? ��� r�."00 Environmental Affairs/MassGIS.The information depicted on this map is I ParcelsF Lp for planning purposes only.It may not be adequate for legal boundary VIA definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING It * THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY " OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT * coy+ �� ♦ ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION SS^CHUS� 1"=101 ft "�• North Andover MIMAP May 27, 2015 65.0-0290 .:w IogII'\ 24.76' 7 wo 065.0-0039 M r `" ! I I01 ! 065:0-0291 J t ! J I I ��• J1 26 MOLLY jT' E RD 1s8 4f 065:Q-UO2_4. r7 065.0-0292 ! J { 34 MOLLY TOWNE RD J* t �Ap, J ! i IpJ 065.0-0293 epos, ! i 42 MOLLY TOWNE RD �p 065.0-0294 �A- 52 MOLLY TOWNE RDf t ♦ S� i / ♦ 9>, 35 ABBY LN / 065.0-0295♦ ♦ ?o 4S, 1 .63' I * i R2 o00s, 065.0-0288 /58 MOLLY TOWNE RD / ♦ ♦ 1 ♦ l 91-11065.0-02961- w , 04\ �f68 MOLLY TOWNE RDt r ♦ 0+65.0-,298 50 MOLLY TOWNE RDM4�� \/ 76 MOLLY TOWNE RD J Igo �`�' 90 MOLLY TOWNE RD 65.0-0287 �I 0k + 065.0-0092 ♦ S�j d� t 151, ♦ N OD i ;• 038.0-0334 ! ! 065.0-0299 Ln 60.97 107.A-0234 158 MOLLY TOWNE+RD may, .-- .._::•:.••-•-• i 106cC=001.1; ;fEr_::.�•:..ti; .:_.: •::••,qtr.•.::_:'yi; 1O 065.0-0304 `�S Rail line -:Wetlands Zoning Interstates 0 Exempt Lands Busine s 1 District —1 0 Busine s 2 District Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, SR0 Busine s 3 District Meters Data Sources:The data for this map was produced by Merrimack ■ Busine s 4 District NORTH Valley Planning Commission(MVPC)using data provided by the Town of Roads M Genera Business District f q O "S o ti North Andover.Additional data provided by the Executive Office of Easements D Planne Commercial Dev ? o++ ,��6 O� Environmental Affairs/MassGIS.The information depicted on this map is .,Corrido Development Dist 3 L for planning 0 MVPC Boundary p g purposes only.It may not be adequate for legal boundary 0 Corrido Development Dist O --• P definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER Municipal Boundary O Corrido Development Dist 1, A MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING Zoning Overlay Industn it 1 District 41 * THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY C Induslri 12 District w * OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT 0 Adult Entertainment # i 0 Induslri 13 DisMct Downtown Overlay District * o a<", �, ♦ ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF ©Historic District 4 IN I S District � < - 0 Water Protection Reside ce 1 District �l +o++"sp. ' .(oJ THIS INFORMATION Reside ce 2 District 7SS 5 t ❑Parcels C.R—ide ce 3 DistH BCNU 0 Hydrographic Features de ce 4 Dis Net —Streams 1"=101 ft " .de ce5 District YYY de ce 6 District --e esidential District i g e „aq. wl'ai.,eaaa .1 1 is DEP FILE#242-1296 I MATCH LINE �J I _< RmRAP a }e� o RCP xuux SEE SHEET 2e m4_.0e-A'� /� I III'II uw,a$art-m+m arv,zixeio+slee,o, ^c. sd•`� I ��� l j 11 mV,T Ix•xmm(Ds t,l '^,n tR °'"eRyn �°J ♦ •' eEGr wExTAm, i �� '��j}j arv,zour-m,.a q,d ----------- LOT 12A ---- EN srno-' tee ------- I NORIIIANOGJER INV;OIR•m,.W ,m� m A s • tm� w!3 °� 'w • ,mjA •/ '°� 9a wAiEn wpm �9� T .,� ° I/ SPIC BEWFR b Y LOT 11 �o STORAGE AREAS:DETENTION POND#1 ELEVA2—IFr.)OEetcu sURFADEA (e9♦ AREA 6-� p ,. - - 7 xoRm.vowe, em eoaE OP y� FOCUS SAP (�/p +0 Rexn mlw. ms,w�o170 1 PApy".) ,mom/ ww+APµ�. ♦ I ��i� ¢ •""e .' 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Enarno Elx,EorPAYEA+ear z. ♦ 1\ ow 1 II TOPPxO. exR �t.'amTmTEI •m.W ouc9.wExux ReALNTRWr IA 1 I I�I I / l 1 1111 9 11 NYOP.VIT -mea CTC eErlm --to__ FmellxO ELEVM,G1 OGaroUrt y 11',\,m�,rro\r ill a ` 1, \1 0 1 ^'w I,l oamrm -p_a.- wsnANo aAa Ara Eor�EaraoROEwxo IIA •� i\ ,`\\\�q l\ami\ rPw eswn, „✓� - wmi m —m— weT,AND /+ RIPR/P t]0811N0 /• , '.e LeRf OF+OO e1FFII,atlxE \ \ \� >m 1SROPORAm - —ts LMROF WN08UM aoxe 7\0 F a - \ `\\+ 1 owai•n�P-,na LOT 6 s"e1 _s— \ LMt MaCNO-0Im1A9 SDNE \ 1__ 1W RIO. WM mi/1 ,S BNN ---- �-- ar cw Gum xEranLrticNEsi re:,• sux rwc sEwm LOT 2 elxa+wrATlw mNrRaL ewmlEm FDfiE OP a o�� Ixvour.am-0Y E9OEOP IIGiDE1UN0�'� I Y LmirosJ- `1 •tm.m ee me M7 PAv°0v?�rPa eY� No .xRon xnum LwroPxCRN vE� OATEO �n. e eA ♦ I wawc I I I +nae taN-�Gr'rr•,ma m�vtx�au�r'-+m"u tiF ''e'/ ces .14 LOT 7 E ;z wmm eLo+ �♦ °�w�almr� Win/ I I aArnxor Pltcln�r,o eCORWlOPAB ,z� a'�"I-�o.m mm Ix�'v;z�iw-alas wAiLnoLwN __w cAnEwlM CRue!® aLw IM/tzw-tPatP ' 81GiEegiOER INV,z OUf-10am °/ "P/� auAcmzoxE I OPEN SPACE B LOT 1 / I xcPP ORAm mizour-mam�,iea Rlcw,00 d/d OPEN SPACE A LOT 6 xGiae "m"N�tSwmm TaPPNo. 01°e Ao o PLANAR I n0 my tzarr-10M ao, rT I i BRVxxORWe OP�m SRV GRAN H OMNT 8 WmEAOOF88 I SCALE:,•=dO eGwNAaE I 1 Q 2 ORAPMOE� oNNe RIM.m1.m ,S RCP OMPI ,HEE s OF 2 CONSERVATION AS—BUILT PLAN P SHEET 1 otos ' mv,zm-,eate(mmae) mv+zm-+once(taq FCR PRo.sssloNAL "AUTUMN CHASE" � ENDINER mv,rw•,n..e wvte•alrr-term 4 mvas•our•tette i _____CROSSCOUMRY DRAIN'C' ,r OProRAm mmoe ���� / '' '/' I 1rTOMM ADe IN M 1. �xPoVN;rw wm - nwx _ Ds.IDEL—E NORTH ANDOVER,MASS. r 8 I mv+raur-+man .- ,r _- ®.t�`�TE7 � Irrv,rour•tmas -- -- ��amm P mv,zour-teooa - _ �pNIN•K we APvucAur: - -man NORTH ANDOVER REALTY CORPORATION 8101 `� 1rrypgWN �0 ,� ,2.OlrT•tma0 ee sPRINO NILL Rwo,NORn,ANDOVER.NA D,t,e OLN7 SUMMER STREET ® PROFESSIONAL ENGINEERSa LANG SURVEYORS '' ew,z m�e> G,P(DELORATE) CHRISTIANSEN&SERGI,INC. ' ieani emai®a) Ixv ioln- w.wv.cs N R. u.rAlERH -A rAx.Mr 2!sw +es.m The Commonwealth of Massachusetts F Depa'r'tment of Industrial Accidents a d I Congress Street,Suite 100 v Boston,MA 02114-2017 •� www.mass.gov/dia '7M SV•y Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lel4ibl Name (Business/Organization/Individual): 1 d S Address: 70 .So `-6rz J 4a j - City/State/Zip: 0 Phone#: q, Are you an employer?Check the appropriate box: Type of project(required): 1.[%I am a employer with _employees(full and/or part-time).* 7. gNew construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance? 14. Other eVAVVh Vl,tA 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] /Q *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 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.#: 1G Expiration Date: �.I 121� ffnn Job Site Address: City/State/Zip: �r 4,r O19 � ' ensation policy declaration page(showing the policy n mber and expiration date'. Attach a copy of the workers c p p y P g Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. certify under thepains ndp alties of perjury that the information provided above is true and correct. I 70hereby Si ature: Date: Phone#: 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 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-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'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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Client#:53642 FAMILYPOOL1 ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE CERTIFICATE 5/11/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WANED,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 CONT ON NAMEACT HUB International New England PHONE 299 Ballardvale St AIC,No Ext:978 657.5100 A/C,No): 866-475-7959 Wilmington,MA 01887 ADDRESS: nee.certificates@hubinternational.com 978 657-5100 INSURERS)AFFORDING COVERAGE NAIC II INSURED INSURER A:Valley Forge 20508 Family Pools&.Patios Inc. INSURERS:Technology Insurance Co Family Pools North LLC INSURER C:Safety Insurance Co 39454 70 S.Broadway INSURER D: Lawrence,MA 01843 INSURER E: COVERAGESINSURER F CERTIFICATE NUMBER: 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 CONTRACTOR 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 ADDLSUB LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER POLICY EFF POLICY EXP A GENERAL LIABILITY MMIDD MMIDD LIMITS 6015920803 9/19/2014 09/19/201 EACH OCCURRENCE $1,000.000 X COMMERCIAL GENERAL LIABILITY pAU4 7 �� — PREMISES Ea occurrrence S 100 QQQ CLAIMS-MADE D OCCUR MED EXP(Any one person) s5,000. X Blanket Add)Insured as contractually equired PERSONAL&ADV INJURY 51,000,000 GENERAL AGGREGATE 52,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY171 PRO- PRODUCTS-COMP/OP.AGG $2,000,000 JECT LOC $ G AUTOMOBILE LIABILITY 3947232 12/31/2014 12/31/201 COMBINED SINGLE LIMIT ANY AUTO Ea acciderd 1,000,000 ALL OWNED SCHEDULED BODILY INJURY(Per person) S AUTOS X AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS x NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ UMBRELLA LIAR $ EXCESS UAB OCCUR 4EARRENCURRENCE $ CLAIMS MADE TE DED $ RETENTION$ B WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY WWC3112837 12/31/201412/31/20ANY PROPRIETOR/PARTNERIEXECUTNE Y/NTATU- OTH- OFFICERIMEMBER EXCLUDED? a N/A(Mandatory in NH) ACCIDENT $500000 If yes,describe underSE-EA EMPLOYEE $500,000 DESCRIPTION OF OPERATIONS belowA Property SE-POLICY LIMIT $500,000 6015920803 9/19/2014 09/19/20itsSpec Form Repl Cost , ded DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more apace is required) Workers Compensation has Blanket Waiver of Subrogation,as required by executed contract.Work in NY is excluded; new construction of 10+units is excluded. CERTIFICATE HOLDER CANCELLATION Town of A hover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1600 Osgood St., BUIIdin 20 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN g ACCORDANCE WITH THE POLICY PROVISIONS. ,,pp Ste 2035 y'+t Andover, MA 01810 AUTHORIZED REPRESENTATIVE P. g g ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05 1 of 1 The ACORD name and logo are registered marks of ACORD #S1378479/M1283395 DKO04 Z i—SWEE Office of Consumer Affairs and Business Re9 ulation 10 Park Plaza- Suite 51.70 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 118201 Type: Suppidment Card FAMILY POOLS& PATIOS INC Expiration: 2/1312017 GLEN WIGGIN 70 S. BROADWAY LAWRENCE, MA 01843 SCA1 t: Update Address and return card.�Mark reason for change. Address Renewal :**- Employment -- Lost Card P�jcc of Consumer Affairs&Business Regulation License or registration valid for individul use only E IMPROVEMENT CONTRACTOR before the expiration date. If return to: Wegistration: 118204 Type: Office of Consumer Affairs and Business Regulation 10 Park Pla7a-Suite 5170 Expiration: 211312017 Supplement Card Rostonj MA 02116 FAMILY POOLS&PATIOS INC GLEN WIGGIN 70 S.BROADWAY - - =� w� . LAWRENCE,MA 01843 [.undersecretary Not valid without sign-T.-w'! 50a-d 3 coristruction Super-,icor —SS: CS-010330 WRIJAM C POUEOS 70 S BROADWAY LAWRENCE Mi 01843 07/19/2015 70 South Broadway 045 Route 125 Lawrence,MA 0 1.843 Kingston,NH 03848 Tel: 978-688-8307 Mid I i Tel: 603-642-9909 Fax: 978-688-1949 SINCF 17781978 Fax: 603-642-9906 providing a full line of services and supplies fully licensed and insured wwrv.familypoolsonlinexom Name w"`,�rr� - r=trf= r' •c ! 1 Date Address r +t �' 1 f .,.' ,C CJI , j �I Al osl s City A r u ,. z, rr State w Zip t , Home Phone _ Work Phone _ Cell ��t'7 ►f ter?l— Addl#— Cross Street/Directions - (a Estimated Start Date Estimated Completion Date We propose to furnish and install ones gunite . swimming pool for the sum of$ THIS PRICE INCLUDES: •Normal Excavation up to 8 hours on day of dig •Manual vacuum cleaner kit •Waterline Tile(6•) -' •Backfill and Sub-Grade up to 3 hours :3-Step•64einless ladder Liner Choice - . s c I ,-.!< ,•_ �aa} rUndewaterWhae Light--n Volt' •Rope and floats •Test Kit •Steel Reinforcing per Engineered Plans for gunite •Initial balancing chemicals •Surface skimmer(s) •Steel Structure per Engineered Plans for vinyl •8 to 12 Wk supply of maintenance chemicals •Dual Main Drains •Over-Flo Line for added protection (supply depends on pool size) Coping •Pressure testing of plumbing during construction •Leaf net •Steps _ -f 1 I a Ct a! I. •Ten Year Plumbing Guarantee(see specifications) •Wall brush :,HandcaL J rJ •Transferable Lifetime Structural Warranty •Extension pole •Filter_._rf_-�= ,_.-C"r _e __r i (plumbed no more than 25ft jfrom pool) •Pump&motor ]r! S 1 THIS PRICE DOES NOT INCLUDE: •Any plumbing over 25ft from pool.Additional runs are not recommended but would be at a cost of$ '"'_._per foot per line. •Machine time in excess of that specified above.Additional machine time to be billed at$ I.1 including machine,operator,and laborer,due with second pool payment. •All hours of trucking will be charged at$ i)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 backfill 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$__L , minimum to $ 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. •Water to fill pool immediately upon interior finish NOTES: ---j r I ,{ s- l�s i t . t . / .T+ ,� t t r, :�l -�. .� ,.,r,t l �c �� t t� R a. l � � frC c �t r n �, -�-r-�,•--r � t7110f, ley(' ( r OPTIONS: TOTALS: Diving Board ( ) _ •� Solar Cover Basic Pool Price $ ? '-+ Additional Pool Lighting r, (.�� �� ) �_—_* r ( -j Options $_ -� �•� Heater Environpool Plus,8 hd+2 surfacel�{� ) _. r{fy�:? SUBTOTAL $ �{ --- Additional Floor Heads _ •- Polaris Vac-SweepZ5%Sales Tax $ Polaris retrofit only ( ) J TOTAL $ LJ '7 r, 7 Swimout/Benchl -r InteriorF9nisi ( } i=-" Less 10%Deposit �$ � a n I) Spa ;: Balance of Contract �i� $ {� 7- Automated Control System -- Salt Chlorine Generator !►(� ({ ..,[t. r J,� `k, ••'}3� ?�' Other If PAYMENTS: 1/3 EXCAVATION 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. BUYER o ' ' date SELLER -r"I date �t.�rr CO-BUYER _date —,1