HomeMy WebLinkAboutBuilding Permit #355-14 - 64 BLUE RIDGE ROAD 10/15/2013 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: � ( Date Received
Date Issued: 3
IMPORTANT: Applicant must complete all items on this page
LOCATION AVE
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// Print
PROPERTY OWNER,J01141y- 17�9f12
Print 100 Year Old Structure yes gno
MAP NO: PARCEL: ZONING DISTRICT: '� Historic District yesMachine 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 [g'Others: / aNJ� FS
❑ Demolition P-Other
El Septic ❑Well ❑ Floodplain El V4etlands ❑ Watershed District
❑Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
ce r°ftT�' A20 %rwt�eazc q/ /X/d-1 /rrwAmdz
Identifica i n Please Type or Print Clearly)
OWNER: Name: Phone: /,"/7
Address: 40 Agot 4 /" / 601!- 5.1�
CONTRACTOR Name: aa�� Phone: 7 40
009(5
Address: �O
Supervisor's Construction License:-°'-, o a J Exp. Date: ' €y
I
Ex
� Home Improvement Licer,ca• _ : .� _ p• Date:
ARCH ITECT/ENGINEER_ a« / ,dti41e--. Phone:
` L
Address, / _ jtr _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.: y Z 16 Receipt No.: 1
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Ownerr ,li,_ � Signature of contract _ 2
G
Plans Submitted rj� Plans Waived ❑ Certified Plot Plan Stamped Plans
Location
No.s � Date /D
. - TOWN OF NORTH ANDOVER
•
Certificate of Occupancy ► $
Building/Frame Permit Fee $0Z-
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check# '
!1
2
J ;01 ' ; Building Inspector
Plans Submitted-Pr Plans Waived ❑ Certified Plot Plan Stamped Plans
'TYPE OF'_SEWERAGEDISPOSAL s .• `;
Public Sewer Swimming Pools
i Tanning/Massage/Body Art ❑ _ g
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
DATE REJECTED: DATE APPROVED
PLANNING & DEVE OPMENT ❑ ❑
COMMENTS I " (91 Tee, J VK, I 1
-CONSERVATION Reviewed on Si nature
i
COMMENTS p st✓' �� c� E',u we�,1.�
HEALTH Reviewed on Si
qnature
COMMENTS
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 Tow;! Engineer: Signature:
Located 384 Osgood Street
FIRE-DEPARTME"NTS' Terhp Dumpster on site yes no
Located-at 124 Mair Street
-Fire Departinwit signature/date
COMMENTS
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 use
C42
Lyee—gr'_L'� V��_j
— Oba
EI Notified for pickup - Date
Doe.Building Permit Revised 2010
Building Department
The following is=a list of the required forms to be filled out for the appropriate.permit to be obtained.
Roofirg, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
o Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
o 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
❑ Building Permit Application
Li Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
a 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)
o Building Permit Application
❑ Certified Proposed Plot Plan
o 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)
Li Copy of Contract
o Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all casts if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submAted with the building application
Doc: Doc.Bui?ding Permit Revised 2012
CERTIFIED PLOT PLAN
PREPARED FOR. 2y,`i.P�jH OF A44
SS9�ti
SANDRA HARZ J G
� B •i
A r NO. 35773
PLAN NO. 9373 64 BLUE RIDGE ROAD ,
S
NORTH ANDOVER, MA. AL LAP1�
NORTH ESSEX REG/S TR Y OF DEEDS.' BK. 13,333 PG. 23
ASSESSOR'S MAP: 65, LOT 19 ZONING. R-1
SCALE. l --50' DATE. SEPTEMBER 20, 2013
NOTE.• EXISTING BUILDING DIMENSIONS TAKEN TO CORNERBOARD.
2
SS.
N04'32'04"E 496.92' r'p Op,
.00
\ 29.3'
`\ PATIO i
\ a
LOT 28A
:::::W: OODDECKo/Zg2/. $2.8' OR NO LESS THAN 10'
\ \
�'� `\\ \\ 75,086 SF. / 3 �s
c,; iso �q��o\ /, PROPOSED R,
uSE'.N IN-GROUND 173'
NO. 64 POOL
w 60'R`1NE F
\velo � a
�O 157.4 \\\`_ —/
30.5' 2 .0' OR NO LESS THAN 10'
SO4'56 55 W 564.35
PREPARED BY
JOHN ABAGIS & ASSOCIATES, PROFESSIONAL LAND SURVEYORS
9 BARTLETT STREET, NO. 252, ANDOVER, MA. (978)-688-4899
JOB NO. 6042
Enter construction cost for fee cal - North Andover Fee Calculation
Construction Cost
$ '556,000.00 m
$ - $ 672.00
Plumbing Fee $ 84.00
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 84.00
Total fees collected $ 940.00
64 Blue Ridge Road
355-14 on 10/15/2013
Inground Pool
NORTfy
Town of . � EAndover
O - 0
No. * t -
h , ver, Mass, 1 C)
coc«ic«ew.cw
�� ADR�TED PPle,�,�y
S 1J
BOARD OF HEALTH
PERMIT LD Food/Kitchen
Septic System
THIS CERTIFIES THAT J.�C 2.� .....�� .... BUILDING INSPECTOR
........... . ............ ...................................
` ' . Foundation
has permission to erect .......................... buildings on ..60.V.....tai . .........................
Rough
to be occupied as ...... .. 'cVA.ee.....�a ....�..,G[/.�!./.. .... ...:................................ Chimney
provided that the person acc&ting this permit shall In every respect conform tot terms of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTS TS Rough
l9Service
.............7I)......................................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Buildinz Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
SEE REVERSE SIDE
C
CREATIVE EDGE
POOLS AND SPA INC.
"Where your outdoor dreams come alive"
P.O. Box 84
Wilmington, MA 01887
Job Name:
/r� e % Mailing AddressStreet: 0 7 Gi/ /(/ City: , 04 State: Zip:
Email: "G Rff'1,ir �ll!< < rdY�. el: ell:
/POOL DIMENSIONS
Width L/E Length Shape/i�� A� Depth I To 6!
GENERAL CONTRUCTION SPECIFICATIONS ACCESSORIES
1. Structural engineering plans INCL. 42. Clay soil-$600.00 per load of 1.5"stonelZO/,roC, //VG
2. Pool layout plans INCL. 43. Additional stone at$600.00 per load
3. Layout pool-Per buyers approval INCL. 44.Owner grants permission to photograph pool for use in advertising INCL.
4. Set pool elevation-Per buyers approval INCL. SALES TAX&INSURANCE
5. Perform normal excavation and remove soil (Exc. Day only) INCL. 45. Payment of all sales tax on pool components and accessories INCL.
6.Access wall or fence: Removed by: /l/ 46.Motor vehicle insurance,workers'compensation insurance and general
Replaced by: Liability insurance INCL.
7. Hand form and shape pool INCL Additional Specifications
8. Steel reinforcing per engineered plans INCL ,r
9. Engineered quality controlled gunite structure INCL
10.Watercure gunite shell twice daily for seven days Buyer
11. Install continuous bond beam around skimmer INCL
12. One set of shallow end steps INCL
13. Swimout or loveseat in deep end INCL
14. Install 6"band of frostproof tile INCL
15. Backfill materials 'Mn�gL ,/j'S/'✓CSE
16. Up to 4 hrs. of backfilling INCL
17. Interior finish INCL
18.Water to fill pool
HYDRAULIC&FILTERING SPECIFICATIONS
19.Approved deluxe filter: Type: -' Size PAYMENT
20. Pump and motor:: Type: Zt,4&0Aa Size
21. Pressure test all pool plumbing INCL. The Buyer agrees to pay C. E. P.S.the following Contract Amount for
22. Hook up all water lines from pool to filter INCL. C.E.P.S's performance of its obligations under this Agreement.
23. Non-corrosive PVC plumbing throughout INCL.
Contract Amount $
24. Hydrostatic valve INCL. Deposit 15% $ 0040
25. Provide return inlets for filtered water to pool INCL. PAYMENT SCHEDULE
26. Main drain suction line with grate INCL. 30% Day of Excavation $ Al
27. Deluxe Skimmer including Weir Gate and Large Basket INCL. 40%Day of Gunite $ Z
28. Pre-cast pad for pool equipment INCL. 12% Day of Tile $
29. Backwash line INCL. 3% Day of Start up $ l�rt1
30. Pool cleaner
31. Sanitizer � ,�pT/�� W/Z-
POOL HEATER$UTILITIES TERMS AND CONDITIONS
32. Deluxe pool heater: Size X20& Make
Indoo Outdoor Na ro THE BUYER UNDERSTANDS THAT BY SIGNING THIS AGREEMENT, HE OR SHE ENTERS
Fuel connection, heater venting, permit BY BID ONLY INTO A CONTRACT WITH C.E.P.S. AND THE BUYER CONCERNING C.E.P.S.
33 . of underwater light(s) INCL. CONSTRUCTION OF A SWIMMING POOL MEETING THE SPECIFICATIONS CONTAINED IN
THIS AGREEMENT,ANY CHANGES IN ANY OF THE TERMS OR SPECIFICATIONS OF THE
34. Electrical bonding of pool as required by city or town codes INCL. AGREEMENT MUST BE MADE IN WRITING SIGNED BY C.E.P.S.AND THE BUYER,AND NO
VERBAL CHANGES IN THESE TERMS AND SPECIFICATIONS ARE PERMITTED.AS PART
35. Electrical wiring and connection from service panel OF ITS OBLIGATIONS UNDER THIS AGREEMENT C.E.P.S. IS PROVIDING THE BUYER
Pool over 75'at$15.00 per foot BY BID ONLY WRITTEN GUARANTEES ARE CONTAINED ON A SEPARATE DOCUMENT WHICH IS
PROVIDED TO THE BUYER.
Heat pump at$18.00 per foot BY BID ONLY THE BUYER HAS THE RIGHT TO CANCEL THIS AGREEMENT AT ANY TIME BEFORE
36. Electric panel upgrade if required BY BID ONLY MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE ON WHICH EITHER THE
BUYER OR C.E.P.S. HAS SIGNED THIS FORM BY GIVING WRITTEN NOTICE OF
HYDRO THERAPY SPA CANCELLATION TO C.E.P.S.
THE BACK OF THIS CONTRACT CONTAINS IMPORTANT TERMS AND CONDITIONS AND
37.Attached. Z� Separate Raised THEY ARE PART OF THIS AGREEMENT, PLEASE BE SURE TO READ THEM. I CERTIFY
Light 1 Blower #Hydrotherapy Jets___46THAT I HAVE READ AND AGREE TO ALL TERMS AND CONDITIONS OF THIS
AGREEMENT.
Veneer TSG Tile G
Spillway size
38. Deluxe cleaning tool(18"nylon brush, hand leaf skimmer,vac. Head, (' CREATIVE EDGE POOLS AND
pole,test kit) INCL. B YERt 61 SPAS INC
39. Initial start-up and 1 hour of follow-up instructions INCL. r BY:
40. Raised Bond Beam:Tile Stone 14 BUYER
Of 6" of 12" of 18" of 24" DATE ' ��� DATE
41.Water Condition- 1 load(18 tons)of 1.5"stone($600.00) L. HIC#166034 CSL#93190
.
,F. wire �(crcta72nJrror,�cl��p�n/jrcrJJcrCtecrJe��J
Office of Consumer Affair.&Business Regulation
<_ ME IMPROVEMENT CONTRACTOR
1 _registration: 166032 Type:
�O F—re
_.w,expiration: 4/13/2014 ;Private Corporatic
CREATIVE EDGE POOLS.AND SPA INC.
DAVID BRABANT
210 ANDOVER ST
I WILMINGTON,MA 01887
Undersecretary
------------
AVAL
Massachusetts -Department of Public Safety
Board of Building Regulations andStandards
x
Construction Supervisor
License: CS-093190 i -
DAVID BRABAN --
54 } I
MCDONALD ROAD ,,;
�= r
WHmin t
g
on MA
81887
f
Expiration
Con3:rnssioner 06/28/2015
ALL SURFACE WATER SHALL
PER STATE COMM CODE - DRAIN AWAY FROM POOL
3-#3 BARS IN BOND BEAM El"0'0'
LIGHT NICHI TOP OF BOND BEAM , " El" 1'0"
ED
IF SPECIFIED
2
3/8'MIN.WATER PROOF b• MAX�T ALL ELEV 2'00
�ENTIRE Pool 3 MIN
� � 4 . A TRANSITION POINT 12 NATURAL #3 BARS G 6"O.C.BOTH WAYSSAFk-TY LEDGE IF ELEV 3'0'
�ON COMM 6 COMM- -DIVING BOARD 12 6" R GROUND
CUT OFF ALT
IF
POOL // BARS ELEV'+'0"
4•WIDE S'ANGLE #3 ®6'O.r-
CUTI
OFF AS NOTED ELEV S'0"
Uzi
tHYMOMSTATIC
a"r 0•
MAIN DRAIN VE 11 CUT FF ALTFRNATE
CONNECT DIRECT TO PUMP 6.MIX 3 MIN. ELEV T 0"
RESIDENTIAL&COMMERCIAL A xCLEAR —
P� WITH BLOCKS ELEV T 9"
ELEV V 0"
SAFETY LEDGE y, Z 1-0 MIR TYP.
FLOOR RE1NF.43 BARS G
I r o c BOTH WAYS TYP.
STANDARD WALL SECTION
2 -
#3 BMS 12"QTC JUNCTION ` _
BOX .. • �® 2!/��Ne 4(m"ctistdarYi dite�adore a4'"!alive
21OAndo�Street Unit n WA-k m,MA o1RR7
WMIN •
Efte P
o Q. 0 1 • • =o- CONSTRUCTION NOTES
2 " !
r REINFORCING STEEL
• � � coNDulr
GENERAL
•' ' ''' �
• CONSTRUCTION SHALL CONFORM TO ALLCITY DEPARTMENT OF • REWMC M SnM SHALL COWORM TO ASTM DESIGNATIONS A-15
PUMP BUILDING AND SAFETY STANDARDS &A.305. LAPS SF•IALL BE A MMIMIWM OF THIRTY DIAMETERS OR
o' •; 18'WHERE SPLICES OCCUR.
EQUALIZER UNE v . • POOL CONSTRUCTION SNfALL MEET T ANSYNSM-S 2003 STANDARDS
FOR RESIDENTIAL INGROLND SWIMMING POOLS
COMM ONLY p q' GROUND CLAMP
• • HEALTH DEPT.APPROVAL REQUIRED FOR ALL COMMERCIAL TYPE
AUTOMATIC SURFACE SKIMMER POOLS GUNITE CONSTRUCTION
11 0 2•#3 BARS(EW) • GUNRE SHALL BE A MACHINE MDIFD AND APPLIED PNEUMATIC LLLY.
DESIGN MIX SHALL BE ONE PART CEMENT TO FOUR AND A HALF PARTS SAND
UNDER WATER LIGHT • THIS DEIGN CONFORMS TO LOCAL CODE BASED UPON A 1:4112 UTL come sTRENGTH IS 3000 PSI®3S DAYS
p' •p REASONABLY LEVE.SETE XAQ APPROVED NATURAL GROUND WITHIN • WATERICE MENT RATIO SHALL SHALL NOT DCCEED,3 112 GALS PER
'p .• O :' Ci 2 F TOP�� AND
GNIXCE3'T10N WILL REQUIRE SACK OF• CURE GUCEMENT
E B A LIGHT WATER SPRAY THREE TI MM A DAY FOR
PLATE� DETAIL
p FRAME SEVEN DAYS.
_ P o o t.. TO caws.p4cT*,v
av'
FENCEA
d #3 BARS 6'O.0 • ENVIRONMENTAL POOLS,EPEC SHALL BE RESPONSIBLE FOR PROVIDING T11�
' o.• o; BOTH WAYS FENCING 1N COMPLIANCE WITH
HYDROSTATIC y
0 ' o.o ..,o'= RELIEF VALVE '' . o•` Cross Secdo117'6"Diameter Spa PREPARED BY
(IF MOT)) .... �, P
COLLECTION ah P — ''b'" r PARA A.PHELAN,JR � �,ZN OF SSS
v y ' - STRUCTURAL.ENGINEER,TUBE OF
18�cIB►d4D) .�: • . Wate1•Ilne 12 SLEIGH ROAD y ,
Gunite CHELMSFORD,MA 01824 �� PAUL A. G
L PHELAN JR.
F
^' r GRAVEL SUMP I; • Rebar(Typ.) 2 H r . STRUCTURAL a+
No.42538
o FILL SPOUT,
IF APPLICABLE • • DRAWING SCALE:NTS NAL
ALL SURFACE WATER SHALL
PER STATE COMM CODE DRAIN AWAY FROM POOL
3-#3 BARS IN BOND BEAM ELEV 0'0"
o �.
LIGHT NICHE
DETERMI
IF SPECIFIED TOP OF BOND BEAM B" 1100
2
3/8'MIN.WATER PROOF 6■ MAX VERT. ALL ELEV 2'0•
PLASM ENTIRE POOL 3 MIN
Pr #3
+ 4 A TRANSITION POINT 12� NATURAL BARS 6"O.C.BOTH WAYS ELEV TO"
SAFETY LEDGE IF Pi
QCOMI� DIVING BOARD 12 6w R GROUND
REOID ON COMM. rCUT OFF ALT
POOL BARS ELEV W 0"
4"WIDE S'ANGLE #3 ®6"O.C.
CUTI OFF AS NOTED EIXV S'0"
MAIN DRAIN HYDROSTATIC
RELIEF VALVE
ELEV 6'0'
CONNECT'DIRECT TO PUMP • 3 MIN. 31 Be.nS ATE a"T 0'
RESIDENTIAL R COMMERCIAL 6"MDC A-OB A .Y'CLEAR
ph? WITH BLOCKS ELkV T 9 V Cr
SAFETY LEGE y.sal Z �inOb
MIN.TYR
FLOOR REBWI
I r O.0 BOTH WAYS TYP.
STANDARD WALL SECTION
2 -
#3 BAMS 12*&C JUNCTbN ` _
BOX � s � • �� ��ie�cyi os `�.or�n. a<comePius/
dative
noA°a�Stant tit n Will►;n$tcw,,?.4A oilUU
° - MIN
2Edge Pools
.0 Q• 0 1 • CONSTRUCTION NOTES
2 ° CONDUIT GENERAL REINFORCING STEEL
PUMP • CONSTRUCTION SMALL CONFORM TO ALL CITY DEPARTMENT OF • REINFORCING STEEL SMALL CONFORM TO ASTM DESIGNATX3NS A-IS
BUILDING AND SAFETY STANDARDS R A,30L LAPS SHALL BE A MftMUM OF THIRTY DUMETERS OR
• o' •; IB'WHERE SPLICES OCCUR
EQUALIZER UNE o • POOL CONSTRUCTION MALL MEET ANSYMSPM 2003 STANDARDS
FOR REST emAL INGROLMD SWIMMING POOLS
COMM ONLY 4 GROUND CLAMP
• HEALTH DEPT.APPROVAL REQUIRED FOR ALL COMMERCIAL TYPE
AUTOMATIC SURFACE SKIMMER Pools GUNITE CONSTRUCTION
2-03 BARS(EW) • GUNITE SHALL BE A MACHINE MDCED AND APPLIED PNELNNATK:ALLY.
DESIGN MDC SMALL BE ONE PART CEMENT TO FOUR AND A HALF PARTS SAND
UNDER WATER LIGHT • THIS DESIGN CONFORMS TO LOCAL CODE BASED UPON A 1:4 1R UTL COMP.STRENGTH S 3000 PSI G 3S DAYS
p' O. REASONABLY LEVE.SITE AND APPROVED NATURAL GROUND WITHIIN • WA7�MEYT RATIO SHALL SHALL NOT EXCEED 3 1f2 GALS PER
. p O :' 2 FEET OF TOP OF BOND BEAM. ANY EXCEPTION WILL REQUIRE SACK OF CENEMT
PLATER SUPPLEMENTARY DETAIL AND DESIGN • CURE GUNrrE BY A LIGHT WATER SPRAY THREE TIMES A DAY FOR
O FRAME SEVEN DAYS.
P®o t. TO "Lf- ccNs i 04 C;r&.o
o FENCE A-1,444V, N A-C C.o A--V ItNt ic,
a #3 BARS 6'O.c • ENIRONMEMTAL POOLS,INC SHALL BE RESPONSIBLE FOR PROVIDIMG TIF
C o, BOTH WAYS FENCING IN COMPLIANCE`MTH
0- - HYDROSTATIC y
:a o . .o•=
RELIEF VALVE '' • o•' Cross Section 7'6"'Diameter Spa PREPARED BY
o . o (IF REQD) ..•r�s
COLLECTION ah P IL �'6" PAUL A.PHBJW.jR N OF*&,
p 1 STRUCTURAL ENGINEBt,
TUBE OF R�D) := • • W tdiine 12 SLEGH ROAD y
Gunite CHELMSFORD,PRA 01824 �� PAUL A.
^' GRAVEL SUMP ► Re�,��.� N.�'1 o PHELAN JR. W
� r � � • STRUCTURAL cn
No.42538
O r FILL SPOUT,
IF APPUCABL.E • e . . DRAWING SCALE:NTS
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
5Y www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electridans/Plumbers
Applicant Information Please Print Le 'bl
Name (Business/Ogw&ad6n/Individual):`
Address:
City/State/Zip: j .` v� Ph �'' _�� J"
��
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ 'I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
working for me in any capacity. employees and have workers'
9. Buil ' addition
[No workers' comp,insurance comp,insurance.$ ❑
required.] 5. �.We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doingall work officers have exercised their i 1. Plumbing re
❑ g pairs or additions
myself [No workers' conip. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compenm
sation policy inforation.
t Homcowoers who submit this affidavit indicating they are 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 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.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
FailLnre to secure coverage as required under 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
Investi on of IA for insurance coverage.verification.
I do hereby ce t* un er the pains�andRgnwves of perju�e_information provided above is true and correct
Si afore: (� Date:
Phone#: ~—
[Other
only. Do not write in this area, to be completed by city or town official
n: Permit/License#
hority(circle one):
Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
son: Phone#: