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HomeMy WebLinkAboutBuilding Permit #051-2017 - 60 PATTON LANE 7/18/2016 NORYM BUILDING PERMIT o`ttLF.D '6�tio �{ TOWN OF NORTH ANDOVER 46 APPLICATION FOR PLAN EXAMINATION � Z y Permit No#: Date Received /R"DR^7ED " c5 Date Issued: IMP RTANT: Applicant must complete all items on this page LOCATION o a Lo - Print PROPERTY OWNER K60�1 a �r-5P1� ��� Print 100 Year Structure yes no MAP I� PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village 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 o Septic ❑Well ❑ Floodplain 0 Wetlands ❑ Watershed District Water/Sewer DESCRIPTION OF WORK TO Bf PERFORMED: u t l d � . V I M L 0 l7� Identification- Please Type or Print Clearly / Z� OWNER: Name: . TA 6A I6VI Phone: 7V',-q 7 Address: LO P � LA JJ•I AIA` `�'r` `` Omik��L %gj�o g-za F;q-W P Contractor Name: poljus Phone: 7��� _�3 Email: ea e. ccm Address: 0(,FV-7 Supervisor's Construction License: 0 to-330 Exp. Date: g7" 0 7 Home Improvement License: 118 Z®Y Exp. Date: 01 - (3 ARCHITECT/ENGINEER Phone: y 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: $ FEE: $� Check No.: Receipt No.: �)6(07 , NOTE: Persons contracting with unregistered contractors do not have access to the guaran fund ��. 9--=ature of --' 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 4. Building Permit Application Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of BuildingPlans One To Be Returned to Include Sprinkler Plan And ( ) P Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code 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 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,etc. x Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF e U FORM PLANNING & DEVELOPMENT Reviewed On �(�`�I�G Signature_ 1 COMMENTS CONSERVATION Reviewed on -211 L( 1 (p Signature COMMENTS HEALTH Reviewed on ' L Si nature COMMS TS c \j Pj L5 mik 0 A �-flu bat E ,Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments v Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPAR�TtMENtTGTempDumpster t.Located at^t124 MamkSt�eet 3 FreDepartmentisignature%iate 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 DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department ease) 4b 4 Ll Notified for pickup Call Email Date Time Contact Name Doc.Buildiug Permit Revised 2014 Location 1_ o e_AA� L t,� -7 Date ��� ,�° • - TOWN OF NORTH ANDOVER • Certificate of Occupancy $ Building/Frame Permit Fee $a� — Foundation Permit Fee $ Other Permit Fee $ A,- TOTAL $ v Check# � 30624 O/ Buildindinspector v Enter construction cost for fee cal- North Andover Fee Cakulation Construction Cost $ 293500.00 m $ - $ 354.00 Plumbing Fee $ 44.25 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 44.25 Total fees collected $ 542.50 60 Patton Lane 051-2017 on 7/18/16 inground pool BUILDING PERMIT OF TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION _ � Z - Permit No#: 74k Date Received IP CC--""�`'e 7 DR^TED Date Issued: �� gSSACHUS IMP RTANT: Applicant must complete all items on this page LOCATION (� rF1' I r6 vi Lv'i Print PROPERTY OWNER KC.V) Print 100 Year Structure yes no' MAP I� PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes. ito TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family WAddition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ "Others: ❑ Demolition ❑ Other �5:vu-,L .. ��,, - 1 yo• ta' '= etl� • i- ,,. ;ef.: ,e i::,fs DESCRIPTION OF WORK TO Bl PERFORMED: Identification- Please Type or Print Clearly G Z� OWNER: Name: J&1i& i9i6,n Aelz, L Phone: Address: �o Pp,%Ceo L�,,x lu4 F41L't Contractor Name: - (1%4v\, P cs Phone: 7LGig 6`7 Email: i �.�y<< L­b� 67(,.C. C:rvtn Address: k4o Supervisor's Construction License: 0 103.3 =' Exp. Date: 0 Home Improvement License: 14 20Exp. Date: 61 ` �3 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: $ A9 FEE: Check No.: �LReceipt No.: ?J6(0 1A NOTE: Persons contracting with unregistered contractors do not have access to the guaran fund +�m. .:av-c.a-�*v.,.:..eo.ec:c-2za^.r.se. ^'-��ssx�•- '*aa ._.... .: _ - .._. ..�.:.._. .. :a:v. � .cv_'va._ee.ays..zu3fx.s��.e�.ixsucasua - -- - _. _._.- _ 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,etc. x Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF o U FORM PLANNING & DEVELOPMENT Reviewed Gn 1 j�`�II G signature_ a IV COMMENTS CONSERVATION Reviewed on11 (o Si nature 6 COMMENTS �►�. HEALTH Reviewed on l Signature COMMS TS r V 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 DE AR1TMENT ,;Temp,Dumpster onisite yes Located at124 Mam*Street. rfx � 1 ' w31 t nature/Pdate p ri ��¢p � ta, � � �y ° Fire Department�sig <q �t'+�- $'" R35''' ``s'�.' +t ; �..{1 � ♦ 7� R v . r1 - µORT1i +• . w: 1 �. .� . . ve' . 0 No. * t h ver Mass A- coc«Ic«e"C 1• 7,9S�R�►rE o ` y U BOARD OF HEALTH Food/Kitchen PERI-T Septic System THIS CERTIFIES THAT .....MAAA.....4...... 0 TIFmq5L D a BUILDING INSPECTOR...(' .. ......... L Foundation has permission to erect .......................... buildings on .. ....A ........................ 1 Rough to be occupied as ...1,,k,�►.�1...... . . . .. .. .�i......`�.. . ..ic�.�,... Chimney provided that the person accepting this permit shall ' every re pect conform to tWerms of the 5pplication Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONS TIO Rough Service .. ..... .. ............. ........ ..... Final BUILDING SPEC OR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. 70 South Broadway 45 Route 125 Lawrence,NM 01843 Kingston,NH 03848 I Tel: 978-688-8307Tel: 603-642-9909 FC Fax: 978-688-1949 srn�ce1978 fax: 603-642-9906 i providing a full line of services and supplies fully licensed and insured vvww.familypoolsonlinexom •7 (�0�( Z O t yr Name l i'A t- Eye_i 1 6�� Date U Zbl� -- �• 4t�Sy�� -Address ?f n1"t�,+ 0^ LAIle, City ! State " Zip Home Phone a �Z 1 !�� Work Phone — Cell Add'!#— Cross Stceet/Directions r r►V t_� __ — Estimated Start Date _ _ _. Estimated Completion Date — 3 We propose to furnish and install one in unite -I,e e swimming pool for the sum of$ 01 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 stainless ladder •Liner Choice - _ *'lttide�nater W1fiIttONt �o1F" •Rope and floats •Test Kit ; •Steel Reinforcing per Engineered Plans for gunite •Initial balancing chemicals •Surface skimmer(s) *2, •Steel Structure per Engineered Plans for vinyl •8 to 12 Wk supply of maintenance chemicals •Dual Main Dr ins •Over-Flo Line for added protection (supply depends on pool size) •Coping_ kC •Pressure testing of plumbing during construction •Leaf net •Steps t •Ten Year Plumbing Guarantee(see specifications) •Wall brush •Handrails. �jG" •Transferable Lifetime Structural Warranty •Extension pole •Filter_. f1 (plumbed no more tharL25ft from pool) •Pump&motor f THIS PRICE DOES NOT INCLUDE: �� �'7 ► ��� •Any'plumbing over 25ft from pool.Additional runs are not recommended but would be at a cost of$ 2per foot per line. •Machine time in excess of that specified abo] ,Additional machine time to be billed at$��} including machine,operator,and laborer,due with second pool payment. •All hours of trucking will be charged at$ W 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. •Co�. qe�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$- minimum to �j} $ 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 d �►�,1 (t wt �� Yt g r1�C ri. -•OPTIONS: TOTALS: Diving Board ' '� ['r'+`� ) --- — (J�� Solar Cover ( ) , _— Basic Pool Price $ Additional Pool Lighting Options $ Heater Environpbol Plus,8 hd+2 surface ( } �_ 0 SUBTOTAL $ F Additional Floor Heads2 5%Sales Tax $ Polaris Vac-Sweep Polo s��.re,�trofit only ( J ) TOTAL $ wimoutdBench A�( U,ri�,t,, 0% i n error Finish � �—. . ., .. _. _ . !t .. _ ( ) Less 1 Deposit ' Automated Control System F { ) Balance of Contract � $ Salt Chlorine Generator Avft IoT ) — Other 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 � � date SELLE at CO-BUYER // date , STEEL WALL POOL SYSTEM ! 18' X 37' K!DNEY 36.11 7/e" DWG#: GS-1110 DATE: 2/13/2008 REV: A PAGE 2 OF 3 TURNBUCKLE BRACE ST-720271 R ST-720271 R ST-72( ST-720271 R 2'-6 1 STEEL Pool PANEL 3' 4" TURNa'C.LE R27-D" PIECE ANOrE emu CONCRETE 4, O„ ST-720091 R FOOTER oEADwN P.SME PLATE Q P M DO C O NOW R9' 0" STA.r 20'-8 1/2" Lo TYP EMBEDDED NUT BRACE ST-720091 R z CUP R5'-0" o m ENSEDDED NU STEEL POOL PANE m CONCRETE FOOTER 4_0„ R5'-0 EAASODL ST-720091 RL 18'-0" ST-48005ORR ST-720091R ST-42005ORR 1 DECK STAKE SUPPORT(OPTIONAL) ST-720091 R ST-48009OR ST-7 RACES AND DECK SUPPORTS AT PANEL JOINTS AS SHOWN E @ ;. 3' 4" 1J _..L 4,_0,6'-0"—A. 14' 0" DANGER:RIVING M THIS DOCUMENT IS FOR ILLUSTRATIVE.PURPOSES ONLY. RESULT SERIOUS. f Alpha 3 Mfg.makes only[f those representations which are stated in Its written warranty.Any other representations,statements,or contracts made by the dealer/contractor to the customer regarding an components attributable to the dealer/contractor only.The dealer or contractor who sells or installs your pool Is an independant contractor and Is no[an agent or employee of Alpha 3.The construction g g y prod NO DIVING INJURY Rfl REATN. to normal ground conditions.There may be additional precautions and/or methods of construction.The responsibility change.-Different methods and re p y methods illustrated here are Sul Signage must be permanently attached around the precautions may be dictated by various ground conditions.This is to be determined yby and is the resron-A safety the contractor who not permanently nn[of attached 1'-0"to the shallow side o perimeter of the pool. be done in accordance with all federal,state and local building codes,as well as A.N.S.I./N.S.P.I.suggested 9 e manufacturer of the componens p signage must be permanently attached to the entire perimeter of the pool.See instructions with signage. -ITISNOT RECOMMENDED TO USE DIVING AND/OR SLIDING SLIDING EQU PMENT ON RECOMMENDED S1 36'-11 7/8" ST-720271R ST-720271R ST-720271R 2'-61/4" ST-720271R ST-720271R 4" R27'-O" ST-720091 R ST-72 e M N � W N ^ N C C O � R9'-O" 20'-B 1/2" � TVP ST-720091R ST-720091R m m M R5'-0" e ENTERLINE R5'-0" R9'-0" ST-720091 RL 186 ST-48005ORR ST-420050RR 1'-4 1/4" FS-9694RBW* ST-720091R ST-720091R ST-48009OR ST-720091R RACES AND DECK SUPPORTS AT PANEL JOINTS AS SHOWN X-4„ T-4.. 4'-0" 6'4" 12'-11 7/8" i r.Il.A I IVI PURPOSES ONLY. "roil Mons which are stated in its written warranty.Any other representations,statements,or contracts made by the dealer/contractor to the customer regarding any components produced by Alpha 3 are �o n Holy I hu 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 suggestions and apply only - - i in nnry Ing midialonal precautions and/or methods of construction.The responsibility is the contractor's.-A safety line,with buoys,is to be permanently attached 1'-0•'to the shallow side of the point of first slopeif k•�i wInm, may be dictated b various round conditions.This is to be determined b and Is the responsibility of the contractor who is not ane agent of the manufacturer of the component arts.--Installation is to ` I �r Y Y 9 Y P Y 9 P P canto 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.I./A.P.S.P.RECOMMENDED STANDARDS-'NO DIVING' - -. P}lAIN u r..hod an ahi,entire perimeter of the pool.See Instructions with signage.-IT 1S NOT RECOMMENDED TO USE DIVING AND/OR SLIDING EQUIPMENT ON RESIDENTIAL POOLS. x The Commonwealth ofMassachusetts . Department oflndustrialAccidents f d I Congress Street,Suite 100 N. Boston,MA 02114-2017 www mass.gov1dia s�• Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNIITTING AUTHORITY. Applicant Information ` © Please Print Legib Name(Business/Organization/1ndividual): i�r��l Address: �0 So L(0 A�UJ" City/State/Zip: �RAXP__ -L109 Phone#: I7 E - (Ott-F,�?a Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with i employees(full and/or part-time).* 7. V5 New construction lam a sole proprietor or partnership and have no employees Working forme in 8. F1 Remodeling any capacity.[No workers'comp.insurance required.] ❑Demolition 3.❑I am a homeowner doing all work myself,[No workers'comp.-insurance required.], 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.E]Plumbing repairs or additions 5. d the sub-contractors on b-contractors listed the attached sheet. ❑I am a general contractor and I have hire � 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. aw4- 14. Other 152,§1(4),and we have no,employees.[No workers'comp.insurance required.] u—iP *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit#his 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-co'n6dors 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: \f aem Policy or Self,-ins.Lic. Expiration Date: I Job Site Address: ( 0 � � City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). 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. I do hereby /cfy(under the ains andpenalties ofperjury that the information provided above is true and correct. Signature:6 ` 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=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 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 FAMILYPOOLI ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 7/08/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: HUB International New England PHONE 299 Ballardvale St C N, Ext):800-370-0642 IVC,No): 866-475-7959 ADDRESS: nee.Certificates@hubinternational.com AIL Wilmington, MA 01887 978 657-5100 INSURER(S)AFFORDING COVERAGE NAIL INSURER A:Valley Forge 20508 INSURED INSURERB:Technology Insurance Co 42376 Family Pools&Patios Inc. INSURER C:Safety Insurance Co 39454 Family Pools North LLC INSURER D: 70 S.Broadway INSURERE: Lawrence,MA 01843 INSURER F: COVERAGES 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. /NSR TYPE OF INSURANCE ADDL SUB POLICY EFF POLICY EXP LTR INS POLICY NUMBER MM/DD MMIOD LIMITS A GENERAL LIABILITY 6015920803 09/19/2015 09/19/2016 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES EaoccuErrrence $100,000 CLAIMS-MADE I—]OCCUR MED EXP(Any one person) $5,000 Blanket Addl Ins X as contractually required PERSONAL$ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY PRO- $ JEC LOC C AUTOMOBILE LIABILITY 3947232 12/31/2015 12/31/201 COMBINED SINGLE LIMIT Ea accident $1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNEDX SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ B WORKERS COMPENSATION WWC3172110 12131/2015 12/31/201 X WC STATU- AND EMPLOYERS'LIABILITY OTH- ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y 1 N E.L.EACH ACCIDENT 1$500,000 OFFICERIMEMBER EXCLUDED? F_N] N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 A Property 6015920803 09/1912015 09/1912016 vrs limits Spec Form Repl Cost $1000 ded DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space 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. RE: Kenia&Escipion Baez, 60 Patton Lane CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood Street,Building 20 ACCORDANCE WITH THE POLICY PROVISIONS. Suite 2035 North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988.2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD i #S1647691/M1524268 CW001 f '' _ I _ _..y. _ _ __. _ _ � . r .. � - - � ♦I ' � ' 1 �� , f i i l � k . 1 . •' ,I 1 � � 3' } I � t i k._ _ _ _ _..._�' '. ._ .-. .. ._.. .. _ - .. . t � � , .. r _. � - V k . . ' I ' � d - .. _ . ^ � 1 .. .. 4 — � . r. as k � I � � { } t. I� ..t�.. rR4. �1�. y i � t . � .�I �� � �.1. .fir. .a i I •� � k'4 J � ` '� � � J .I�• .. ,r. i ' — i s + .l i; ". Office of Consumer Affairs and Business Regulation c7 �� 10 Park Plat a - Suite 5170 Boston., Massachusetts 0211.6 Home Improvement Contractor Registration' Registration: 118204 Type: Supplement Card FAMILY POOLS& PATIOS INC Expiration: 2/13/2017 GLEN WIGGIN 70 S. BROADWAY LAWRENCE, MA 01843 _._.-----------__-=' sc 20r.405: Update Address and return eard.'Mark reason for change. Address Renewal Employment -' Lost Card of Consumer Affairs&Busiaess Regulation License or registration valid for individul use only INE IMPROVEMENT CONTRACTOR before the expiration date. 1f found return to: registration: 118004 Office of Consumer Affairs and Business Regulatiotk Type' 10 Park Placa-Suite 5170 Expiration: 2/13/2017 Supplement Card FAMILY POOLS&PATIOS INC Boston,MA 02116 GLEN INIGGIN 70 5.BROADWAY - 4V1+REP:CE.NA 01843 Undersecrctary Not valid without signature 64Pa Aryl V$%1.i J t C,jtYk i f'\'bl LAi S�6I�i1�3 itY 14f !ai4il l�.i�l l+lA.�.> tbSlaai ukNfel! 3ttt;i i t ist3i' 4° License: CS-010330 r t. 1 ?s r i q p'*VnNCE W 016k 'cimlr is iQnPr OW19/2017 i ,9