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HomeMy WebLinkAboutMiscellaneous - 242 DALE STREET 8/4/2015 OORTil BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 41 c'A'"r,cE"a' Permit No#: Date Received SSSS U C Date Issued: Li L LIL �6, IMPORTANT: Applicant must complete all items on this page LOCATION c1 ` Ty Print PROPERTY OWNER 1 t �Qa) 0 Print 100 Year Structure yeso MAP PARCEL: ZONING DISTRICT: Historic District yes i Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential D New Building 0 One family 11 Addition El Two or more family 11 Industrial El Alteration No. of units: 11 Commercial 11 Repair, replacement Li Assessory Bldg [I Others: 11 Demolition XOther DESCRIPTION OF WORK TO BE PERFORMED: 'V'e 6-re961ellid Identification- Please Type or Print Clearly OWNER: Name: �, L�,Aie- Nw tn Phone: (Q J Address: 4-5 Oen ve A.,1 0. 14 Contractor Name: f l Phone: 6,1'63 �'VE —33-/7 Email: Address: We7jrk� &,tol "Aloe 9 lee,,W v17 a Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: 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: $ I FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Ns _q nt/Owrj� Aw Plans Submitted ❑ Plans Waived ❑ Certified Plot Flan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. ❑ Pennanent Dwnnpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On j � Signature ... , - COMMENTS Z/11011'1/— CONSERVATION ,1 `�/CONSERVATION Reviewed on d Signature COMMENTS c _- I HEALTH Reviewed on -` Si nature 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 Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster onsite -yes no Located at 124 Main Street Fire j- #rfm—e,nt sig"natureldate COMMENTS I rim t%ORTH -% dover An e '' _t own of 1 ® t h ver Mass lJl o s4 �, ° � 1. > > COCA. LAKQ Kt CHl WIC. V � U BOARD OF HEALTH Food/Kitchen PERMIT T L �D Septic System a THIS CERTIFIES THAT :. ..�.. ,, ,,,,,,, , BUILDING INSPECTOR .............. ..... .....` .. ... ..... .... ....... ....... .... Foundation has permission to erect ........ ................ buildings on ......�:Z7....t-.... .. .................................. /� Rough to be occupied as ........... ... . ..... ....... w' ... ! 1.�a. .. ......... Chimney provided that the person accepting this pe shall in every respect conform to the 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 PERMITI IN MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION RTS Rough . Service ............................... ...... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® 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. � � � i Family Pools North Aoceunt# Al 3052 3Newton Jct. Road � Unit 4 Estinahy# a11667 MinQsbmv\ 80f03848 0mba 6o2x2015 7e/(603)642-9909 Estimate Amt $10.284.04 � Planned Start 8/3/2015 Planned Completion 8nm015 Rob Barter 242Dale St /VAndover, &&4Qf&45 � � Amount Remitted � Estimate Date 6/22/2015 Estimm/e# S1 1667 � Description Pool Purchase and Installation.7'DoopEnd. NOTE:Excavator charge iaestimated. Fina||charge will babased onactual Item# Qty. Unit Price Tax Total 1 1.00 Each $1.750.00 $0.00 $1.750.00 Installation-15x32Pool 3 1.00 Each $0.800.00 $0.00 *0.000.00 Palm Shore 10'x3c Platinum Pool Kit includes: 1'125'x40'VunHose,8G.o'1.o^Hayward Thm|ineBall V|v M|PxF|P.1'1OXnuSolar Cover,8mi|.14x15'AjrPillow,O.O8'8'AnudizvdTelescopic Pole Caue.1+\nnorShield Floor Pad, 16x32 Oval,l-Calcium Chloride,50 LB Bag,0.02-DE Scoop-CASE,1-EnergizerPlus Shock, 1 LB-12 Ponh.1'Ladder,A,Fmmo.Evo|uUun.O.O8'bamoVao Way Test Strips,0.O8'LoafSkimmer Head MBP Cauo.O13'pM Builder,5 LB Case,0.17-Premium Vinyl Liner Vacuum Casej-Pristine Blue Mini TestKit.U.O8-phoVnoBlue Qt. Case,o.nu'PristinoCheck Qt. Case,O.O4-PrimineClean Spa,80ZCaoo.O.1a'Reduunro00O.OLBCaoe.1'notum Winterizing Plug,w/O.O.n-Tota|Control 10OU.25LB Caoe.1'U|tmVac Automatic Pool Vanuum.0J-WaUFoam, 3 1.00 Each $265.00 $0.00 $265.00 10'x32'K0in1yFalls 2DMIL Expandable Liner � 4 1OO Each �ornOO �UO(1OoO0Y�O� ��O0 $0.00 � � � � � � PLDoO.3OGFoEFilter v/l HP'Included inPackage Price u 1D0 Each $135.88 $.0O(lo0.Oo%Off) $0.00 $0.00 Ladder, Dek, Evolution'Included inPackage Price 0 1.00 Each $150.00 $0.00 $150.00 Mid Size Excavator Mobilization Fee 7 5.00 Hours *150.00 $0.00 $750.00 Mid Size Excavator Hourly Ram. Dig time estimated based on dig in clean h||and for digging out 1 stump. Final billing will bebased onactual dig time. 8 1.00 Case Of2 $77o0 $0.00 $77.00 Main Drain,Hayward,Vinyl Family Pools North oNewton Jet.Road Unit* mvoomu.m*oonwo(6ox)o*x-9ooy(pmone)NnuN42-0000(pmx 71812015 5:51:46 PM Page Ynf 2Pmge(s) 9 3.00 Each $2.96 $0.00 $8.88 1.5"Male Adapter MIPT x INS 10 3.00 Each $2.03 $0.00 $6.09 1.5"Female Adapter FPT x SKT 11 1.00 Each $8.45 $0.00 $8.45 1 1/2"Tee INS 12 40.00 PER/FT $1.08 $0.00 $43.20 1.5 Black Poly Pipe 13 1.00 Each $56.49 $0.00 $56.49 Jandy 1.5-2"3-Way Valve 14 1.00 Each $4.72 $0.00 $4.72 1.5"Elbow 90 INS 15 1.00 Each $14.21 $0.00 $14.21 1.5"Flush Union,SKTxMPT 16 1.00 Each $350.00 $0.00 $350.00 Main Drain Installation Totals $0.00 $10,284.04 Payment Scale Amount Due Deposit with Contract Sighning $3,599.41 Pool Delivered $3,599.41 Pool Complete $3,085.21 Installation includes:Level ground to within 6 inches of existing grade, patio block under uprights, errection of pool with stone dust and foam pad on floor,installation of liner,and set-up of pump and filter. Electrical installation, electrical permit and building permit not included in pricing. Water to fill the pool is extra. Excavation over 6 inches is extra if not specified herein. The removal of excavated material,and fill material needed are extra if not specified herein. It is the responsibility of the owner to provide adequate access.Damages occurring to areas of access by normal means of construction are the responsibility of the owner. Water and electric to build with is to be provided by the owner. The owner is responsible to see that the pool is built within the established set backs established by the local legal authorities. Products supplied by this agreement are subject to the manufacturers' Warranties. Completion dates are subject to weather and conditions. Work not itemized is extra and will be charged time and material. Family Pools reserves the right to discontinue work if payments are not made as scheduled.A 2%finance charge after 30 days will be applied to accounts over due. When collections are needed, attorney fees and court costs are collectable. Prices quoted are good for 90-days. Signing constitutes acceptance with deposit due. FINAL PAYMENT WILL BE CASH OR CHECK ONLY Signature: Date: Signature: Date: Family Pools North 3 Newton Jct.Road Unit 4 Kingston,NH 03848(603)642-9909(Phone)(603)642-9906(Fax) 7/8/2015 5:51:46 PM Page 2 of 2 Page(s) The Commonwealth of Massachusetts Department of IndiustrialAceldents 1 Congress Street, Suite 100 Boston,MA 02114-2017 vet www.mass.gov/dia s,. Workers'Compensation insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information ,Please Print Legibly Namc) (Bttsiness/Organization/Individual): 19b"� Address: /,e 7 City/State/Zip: -� g e—'? 1105 hone#: � A ®✓s� Areyou an employer?cl eck&e apapliropriate box: 'Type of project(x'equired): l.E?fX am a employerwith .�employees(full and/orpart time).* 7. ❑New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required] 9. El Demolition 3.❑I am a homeowner doing all work myself,[No workers'comp.insurance required.]f 10 E]Building addition 4.F1I 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 1 F Electrical repairs or additions proprietors with no employees. 12.E]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. 6.❑We are a corporation and ifs officers have exercised their right of exemption per MGL c. 14.RJ Pan �CN57/i:llu/�c� 152,§1(4),and we have no;employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. T 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-conlracfors have employees,Viet'must provide their workers'comp.policy number. lam an employer that ispioviding workers'compensation insurance for my employees.'Below is the policy and job site information. f Insurance Company Name: f C d Policy#or Self ins.Lie.#: M y q 3 C10 0 �"l � Expiration Date: 5-Z d A00/12 Job Site Address: /k' 5 f! City/State/Zip:,(/f vrA 0Ve9, Attach a copy of the workers' compensation policy declaration page(showing the policy number andexp!ration 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 certify under the pains andpenalties ofpeijuiy that the information provided above is true and correct. Sign �� '��� ` Date: G� Phone# U ._ ` � —,-9,-7-5 Official use only. Do not write in this area,to he completed by city or town official.. City or Town: Permit/License# Issuing Authority(circle one): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: AC R" CERTIFICATE OF LIABILITY INSURANCE DATE(MM,DDlYYYY) 8/3/2015 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(les) 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 Victoria Lowes, CISR MTM Insurance Associates MIN. Ext): (978)681-5700 AIC No:(978)681-5777 1320 Osgood Street ADDRESS:vickiel@mtminsure.com INSURER(S)AFFORDING COVERAGE NAIC# North Andover MA 01845 INSURER AAtlantic Casualty Ins Co INSURED INSURER B:Preferred Mutual Ins Co 15024 Attics To Basements Construction LLC INSURERC: 187 Wash Pond Road INSURERD: INSURER E: Hampstead NH 03841 INSURER F: COVERAGES CERTIFICATE NUMBER:15-16 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MMIDD/YYYY MMIDD/YYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TA CLAIMS-MADE �OCCUR PREM SESOEa occurrence $ 100,000 M143000293 5/6/2015 5/6/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑ PRO JECT ❑LOC PRODUCTS-COMP/OPAGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY COEa accMBINED SINGLE LIMITident $ 500,000 B ANY AUTO BODILY INJURY(Per person) $ '.. ALL OWNEDX SCHEDULED PCA0100709197 8/12/2015 8/12/2016 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Peraccid ' $ Uninsured motorist combined $ 500,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION_$ $ WORKERS COMPENSATION I PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ '.. OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) This certificate of insurance represents coverage currently in effect and may or may not be in compliance with any written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Family Pools North THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 3 Newton Juntion Road ACCORDANCE WITH THE POLICY PROVISIONS. Kingston, NH 03848 AUTHORIZED REPRESENTATIVE L Mancinelli, CIC/SAM Y'.' ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS0251901401t Massachusetts-Department of Public Safety Board of Building Regulations and Standards �4➢'94r L,i'LSSiiS X13 i3i:.4F�:('fE .�...:r _�" License:CS-010330 til T l:ti � WILLIAM C POUJbs - ''�i ✓�� 70 S BROAIDWAY LAWRENCE Old '�, a• 6✓ - " "t Expiration Commissioner 07/19/2017