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� � Tlie Commonwealth ojMassachusetts
DepaKmext ojlndustrio[Accidenis
Office of Investig�tons
� 600 Wasliington Street
Boston,MA 011ll
www.massgov/die
Workers'Compensation Insurance AffidaviE:Bui�ders/Contractors/Electriaa�os/Plumbers
� Aaalicant Intormation Please Print Leeiblv
Name (Husi�essl0'�nization/Indtviauan: �` �s �'�h�1��W S
Address: �c 1��!1�('��� c,Zc.� ����c'�P� ���bb2-
City/State/Zip: �M`A SS 6��6b`Z� ',:..:=+: . Phone#: �' ��2� �:9��0
,:.
Are you au employer?CLCck the`ayProp�iue z: :� ,
ue , Typc dproject(rtqaired):
1.� I am a empbya wiih `� 4. I am a geaeaal oonfraaor and I 6; ❑New consaucuon
' empbyoea(full and/or part-�e).• Lave h'ved the sob'�ountracoma
2.O I am a sole proprietor or pazmer- liscod on tbe auached shat. = 7. ❑ Remodeling
ship a�Lave no employeea 7'hese sub-contractms Lave 8. ❑ Demolition
workmg:fqr me in any.capacit�f• workqs' comp.msurance. 9. Q g�8 addit�n
[No workeis' comp,insurance . 5. ❑ We are a corpoIation aod iffi'. • 10.0 ElecUical aus or additions
reqa'ved.]_� �:. .,.: > officas Lave exe;c�sad thea �
3.� I am a homeownec.doing all work right ofexempdon pec MGI:� I1.Q Plumbing tepa'vs or addit�
I mysei� �vo wmkc�,r�.com�-. , . c. isz,gi(a7>and`v,veLave'ao ,12,� Roofrepaas
insurance required:;y t. . . . . �PbY� [N.o woticels' , ' .
comp.msurance requved.'J` 13.� Other I 1 L
'�r BPPlicmt thet checta box Mt�K eleo Gll out�(�xction betow ehoamQ thec awrlEps'w�e�eo�pon D?h�Y ID�mation- .
t xo��wbo��mt mn`eesaa�i mm�m��aoma en�t�a e�eue�aifmde wntia�twt riiint submit�ma effidevit mdicatina sueh
� tContrecoms tMt cfieck thie box'�et ettacLed m edditioosl�eheet ehowu�th mm�.oft5e�euboontrecfms md 9xiE workm'comP•Policy roforrt�etioa
I am ry►'employer that/s providtn;worker�'compauadoa lnsuraiietjor inq eiilp�oysia: Betow 1�thepoUry ond fob site
lnjorniaHoe. .
Ins�aana ComparryName: _�I�t�-'O� r�,�Y\� . .
Policy#or Self-ins.Lia #: t-.�C A. .O�''.��2\3- \Cl Expaation Date: �• \ � o�
Job Siu Addnsa: ���fTo�-, �,�(Z�`Q. � City/StatdZip: �'c�`'�`r�
Attach a copp of the wor�ere'compensaHon poticy declarstioa page(showing the pollcy nomber aad eapiratton date}
Fa�7ure to sceure coverage as requirod under Secdon 25A of MGL c. 152 can lead to tha m�position of crimmal penalties of a
fine up to S 1,500.00 and/or onayear�prisonmen;as weA�civ�7 pwalties m t�foim of a STOP WORK ORDER and a fine
of up to 5250.00 a day againat the violaror. Be advisal tLat a oopy of tLia staument may be forwarded to the Office of
Invatigaaons of the DIA far msurance coverage verifip�n.
7 do hereby artlfy under the palnr anapenaltict olP�d+�'thaf du injorinadon providea above Lt dws ond correct
SiAnaWre• Date .� " oz � � �
Phone#:
O,aJcla!rue only: Do nd wrltt 1�tkb anq to bs co�npldid by dly.ai town oJjlc(nL
Cky or Town• Pe�.mWLt«nae#
Issuing Authority(circle one):
1.Board o[Healt6 2.Building Departmeut 3.Clty/fown Clerk 4.Electr(cal Ia9pector 3.Plumbiug Inspector
6.Other
Cootact Person: Phone#•
Information and Instructions
Massachusetu General I.aws chaPur 152 requires all emplayaS m Pro�4 workas' comPensauon for their emq�loYe�.' :
pursuant to this stamte, �e�Ya is defined as"...evuY_Persrson in the savice qf another under any contract of hire,
oxpress or implied,o�or written." ;
An enrpbyer is dc5ned as"an individuai,Parmersh�p�ass�t�°,°0tP°raaon or other legal entitY,ot anY two or mon
of the foregomg enBaSe�1°a loint entapcise,and'mclndinB du 1�a1 r�Fcesmtatives of s doccased emPby��or the
recciva or uustoe of an individuai,PartuershiP�assoc�tion or other legal entity�emPbYmB emPbYae. However iLe
owner of a dwelling house bavinB not mon than thra apar�nenls
and who resides therei4 or ihe oua�Pant of ibd''
dwellmB housc of atiother who emPloys Persons ro do mainunance,conswcdon or repair worlc an such dwelling house
or on the�ounds or bu�7dm8 aPP�a°t thereto sLall rot because of such employment be deomed Lo be an emploYa•"
.
MGL cLapter 152,§25C(�a�s�staus that"every st�te or local IIcensing agency shall withhoid the issasnce or
renewai ot a Heense or pvmit to op�rate a basiness or to consUuct baildinB�in tlu common�realth tor any
aPPlicsat who hae uaR prodaced ncceptsble cvidmce of comptlance wHh the insonna coverage re9dred•
AdditionallY,MGL chaPta 152;§25C('n staus"Neither the commomveahh mr any of ita poli�cal subdivisions sLall
entea intn any conuact for the perfoimance of public worlc unUl acceptabie evidence of compliana with ffie insuraace
tu bave ban resentcd Oo the conkactinB auttoriry."
rcquirements of thia cbaP p
APPtleaMs ,,; _, .
the boxea that app1Y to Yav situation a�,if
Please fill ont the workers' compeosadon atfidavit compleulyho e number(a�along with thevi certi5cau(s)of
necessary,suPP1Y sub'�°nuacto�(s)name(s�address(es)and p with no employees other tl�the
insurauce: Limited I.iab�7itY ComPanies(��)or Limited I.iab�7itY PartnecshiPs(LLP)
members or pazmas, are not ra►uired m canY workas' qompensation insurance: If an LLC'or LLP doea have
�pioy�e,y,a policy is required. Be advised that this affidavit maY be submitkd to the Daparuneat of induati'ial
Accidcnts for canfitmation of insutana coverage. Alw be..sare to sigo and date the sflidsvit. The aPfidavit shonld
be reuuned to the city or town tLat tLe application for ffie permit oi license is being Te4nested+uot the Department of
Indusfial`AcxideNs, Should You Lave any questiona regaidin8 the law or if you are reqafrcd to obtain a workeis'
call ihe Dep�ctrnent at the nnmber ljstod bebw. Self-rosurcd companies s�uld enter theit
coa�pcnsationRolicY;please. on ihe ' u line.
sclf-insurance licensc� _
Cky or Towe Of6eiaU �
Please be sure that the affidavit is compleu and prmted legbly. The Depazunent has provided a space at the botrom
of the affidavit fm you to ffi out in the event the Office of Investigations has w contact you ngardmg the apPlicant
Please be sure to fill in the permit/ticense numba wlrich will be���need only submit n affidavit mdi�g ciurent
that must submit amltiQle pecmit/license aPPbcations in anY�' Y
policy infomiation(if necessazY).and,�"Job Siu Address"the applicant slauld wriu"all locatioffi in (city�
town)."A e�}py of the aff'idavit ihat has been ofliciallY sta�cd or marked by ffie city ar town may be provided to iha
applicant as proof ihat e val�d af�davrt�s on fle for fumre permits or licenaes. A new atI'idavit most be filled out each
year.Where a home ovwer or citiun'is obtaminB a license or pumit not relaud to any business or eoam�ercial v�mre
(i.0 a dog liccnse or pecmit Lo burn teaves ete.)said person is NOT requ'utd oo comPlete this affidavit
The Otfia of Investigxiions would like to thank Yoa in advance for your coopuation and should yon Lave any questions.
pleaae do mt hesitau o0 8n'e us a call:
The Deparm�enYs address�telephone and farz numba:
The Commonwealth of Massachusetts
Deparlment of Indushial Accidents
OfHce of InvestigaUone
600 Washin8ton Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE '
Fax#617-727-7749 �
ttevised 5-26-os www.mass.gov/dia
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CITY OF SALEM
DEPT OF PUBLIC PROPERTIES
ABOVE GROUND POOL INFORMATI0111
PRIVATE POOLS—CONDITIONS
I. Private Pool—Definition
Any pool intended to be i�.sed primarily by occupants of a one or twafaznily dwelling. Any such
pool more than 24inches deep or having a surface area greater than 250.square feet (18-foot
diameter) requires a building pemvt before installation, enlargement or alteration. i
II. Permits . ..
Applicarions for a pem►it shall be accompanied by a certified plot plan (scale not less than 1." _
20') fully dimensional, showing pool location on property, relation to adjacent shuctiues on
property, relation of adjacent structures on property, locarion of all fences and gate.
III. Pool Location.
No side of any poot shall be ciosure than six (6) feet to side or rear properry lines. Poois are not
allowed on front yards without obtaining Vaziance from these requirements from the City of Salem
Board of Appeals.
N. Safetv Requirements
Pools will be surrounded by a fence at least four(4) feet high and no further than 25 feet from the
sides of the pool. Rail fences will not be permitted. One, 3-foot wide gate with closing and
locking device will be pemvtted.
�
V. Electrical Reauiremrnts
After receiving a permit from the Building Department to construct a pool,the installer must
obtain the service of a licensed Electrician to do all required elech-ical wiring and grounding of the
pool. License electrician is required to pull elechical permit from Electrical Department. (The
Electrical D artment is located behind the entral Fir tati
nd
ep C e S on, 2 floor.)
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licant)
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Nk>!i STREET USA
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SURVEYOR'S STAMP
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' CITY OR $ALEM� MASSACHUSETTS
• • PUBLIC PROPERTY DEPARTMENT
�2� WASMINGTON 57REfiT, 3RD FLOOI�
$A�EM, MASSACNUSETT3 Ot970
STANL[Y J. UlOVICZ. J11, TEIEPMON6: 978-743-9393 EXT. 380
M�ro� F�x: 978-740.984Q �
Salem Buildlna I�euardnent
Debrls Disnosal Form
In accordance with the provisions of MGL c40 S 54, a condition of your
n
Building permit is that the debris resulting from this work shall be di
s sed
of i
n a ro . . Po
1 lice
P p� y nsed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in:
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(Locadon of Facility) �� • �/�-��I n. ��pj✓� �
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Si a e o Applicant
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Date
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A�PS� 03 03 OS •
� �� THIS CBiiff[CA7H IS ISBU�A9 A MATiPA OF ViFORMNTION • ,
Aittra e Insuranee ��YANG CONFER3 NO RIGHT9 UPON iHE CERTIFiCATE
dg I�geaey Zpc ` HOI.pER.THI8 CER71flGATE COES HOTAMEND,IXTEND OR �
1558 OtiB St.. P..O. BOa 1129 AL7ER7XECOVERAGEAFFORGECBYTHE�POtJC1ESBELOW. .
Norehboro t9� 01535
Phone:S08-393-7744 Pa�u508-393-6983 IN�IRERSAFFOROINGCOVERAGE . NNC#
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CEATIFlCATENOLDER CpNCELLATION
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ACORD 26(2001J08) � O ACOAD ' TI 1988
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BDARD OF BUILDING REGULATIONS �� '�
Lieense: CONSTRUCTION SUPERVISOR � .
,�, �. ,� Number. CS o27889 � �
�� """ Birthdate: 031t411934
Expirea:03114@008 Tr.no: 77761
.._.._ _ . _ ResVicted: 00 � I
RODNEY P ANDREWS
7647 LOWELL RD ie � Kgd,q„ , , '
CONCORD, MA 01742 � C � oner' �
_. _._. . . 1 . �
� ��O`[90'ANX6%tL/X)![l(R O/✓!�4](fllf!/dQ�d '
- _ BOBfd O�AUIIdIII�Rl$YI&H009 dPA SIBIId9�A5 �License or reglmstion vatld tar indYvidol ase only �
; ,
HOME IGAPROYEMENT CONTRACTOR ' Ix(arethe exp3ratloa date. If fonnd return to: �-
- Board of 8uildiug Regulatlons and Standards
�
. - Registrahon: 113772 - pne Ashburton Pluce Rm]301 .' I
Explredon:-7l75Y1OD7 Bps[on,RTa 02108 � '�,
TYPe; Private Caryoration
ANDREWS GUNITE CO.,INC. ,
RODNEY ANDREWS � `
6 REPUBLIC RD �,G,.,,�� i �
N BiLLERICA,MA 01862 pdmloislretor � IVot vall withouf slgualurc j
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f���: .�.x, , , , q 161 Holten 5treet �
�=�a y �,�s� S � Danvers, MA 01923 '
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---' t NOTES : GENERAL SPECIFICAT►ONS:
� �' ��.-' �
� � \ 9. Two 2 A ua-doc ma nets. °A� February 2t, 20os
S�i4CK UNE ; � � s�e: cu�
,,,,.-'� �� � 2, � s¢E: 16'X32'
; �` \ DEPTH: 3� ro g�
' � 3. Ste►B for Polaris. "�a 454 ga�T• P�� sa�se �T•
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\ �� �� \ POOL CAPACITY: GUS
� ; ; � 18,600
� � ` MOTOR�oo�: i
� � 4. , PeMaer 'WhispertJo' �
\ � � MOTOR: � ��j Hp.
� � �
� �
� 5. 3 ste s w/ 4'benCh �off 2ttd F���R Penta►r FNS DE 48 S4�T•
� Sfe, . VACUUM LINE 8 SKIMMER:�R ��@ Z�
� `�` `��` RETURN LINE:
� �� � . MAIN DRAlN: tI7�@@(3�@1 1/2"
� � 6. 4 euferiorswimocr� TWo(21�2`d�ct �
` � ; � SI4MMER-MooF1: pac Fab Penfalr-Cycolac
�� �
�� �� � 7. Cantilever ed�e. HE^�-"'o°E`
� �` � HEATER sN �
� �� �\ � 8. one 1 500W lighf. FUE�:
�` �� DRAFf DIVERTER: NO
\ �� � \ TIMECLOCK:
� � 9. U to 4 hrs: backfrllf f22ov
� \` �� 6�� f e rade & 1 load of P�LCIEANER stub for Po/ari5 vac sweep 28
� �j rocessed c�ravel. INFLOORCIRCUL4TION:and�eWS i4f/V. 1Q 15 �'
� �
� �` �` SANffIZING SYSTEM: VISl00 Nature2
� �\ — — � 10. H drostatic relief Kalve & BA���H' F�ffIR
`� _..� `. � ton afstone included. ELECTRICAL: p��
\ � � ��..�R�/ \ '� �` �
ELECTRONIC CONTROLS: I
� '•� ; � COPING: �.
� �` '�/ {$i •. ` CantiietAEr
� Brushed Concrete DecFrA= TILECOLOR:
6,��` ��•� 4 Rs• �Z''�" Rg. ��`�`� ` 600 sq.ft, byAndrews v�r/up to BENCH: OA@��� 4=O" off2ndstep (
� \ sr � ` 4 hrs. gradeldeck � ? lx�atf crf sTEPs Ftrree(3) rora� � �r.
� � � � � � �
� � j� 3,-io„ 23 � �� '� processedgravel. s�nMour: �g-x4•exter�or
� ; 41 �y. F BOARDSIZE CA�OR:
sdow, f '3•�--�" � � . LADDER-MODEL'
LIG� � � -�T R7, T1'�" `` � \ ' ROPERINGS: YES OnB(1) w/aoaE6Fl.oaTs
� one � 500ttt�lilQV.
� � :t � _ ucHr: - ( 1G�
\ i ` , �ecK av: Andrews
� �; '� R6' 3 STEPS W/4' :l �4 SETBACKS: 6. sroe s. Ren2
" � ' BEPlCH � �� •
\ . , : — _ , 1Q... seanc Tarac 2�. �acHrt��tn
\ • 4 b`7Cr6RfdR " /' � SfDE PROPERTY s��n�
S�WIINU6lT_.._ ./'. ..� / �F � LINE WATER FOR GUNITE: No
� ` �,.
�!! Sft@
�� �; • _.._..�•• �` , sPa None s7eP: None �
`� �` F , a�: sa�r.�R �r.
` AIR BLOWER: HP.
SIDE PROP TY � O SETBACK�.INE �
UIVE �� � � BOOSTER PUMP. HP.
` i v � t JETS: REiURNS:
\ \ �' POOL � NO GRAD/NG UNLESS SPECIF/ED
EQUIPMENTS �� EQUIPMENT �� OWNERRESPONS/BLEFC�R: or�rrnwa��: sPiu.wAv: �
� t ; LlGfif:
� HEATER �` ; ` 1, DETERM/NING ELEVATION IOF POOL
� FILTER AC ESS �
� � ON DAY OF IXCAVATION.
I � � � 2 FEfJClNG OF POOL AREA PER
�� PtJMP � � ' WATER FEATURE:
PLUM6ILJG ` � ` COUNTY OR ClTY ORDINANCE. 11[orre
�� � S2E: WxDxH
� � � 3. GAS LlNE& VENTING OF HEATER.
� SKiIMMErt \ � � � 4. WETTING DOWN CONCRETE SHELL PUMP: xP.
�—� `� � �� AT LEAST TW/CE DAILYFOR ADAYS.
PIETtfRN ; ; ` DIRECTDRAIN: JANDYVALVE:
p"O DIRECT MAIN DRAINS \ � ; i
� 5. DO NOT TURN ON POOL LIGHT
� %' WHEN POOL 1S EMPTY.
�J-� sTUe wR POUIRIB \ � �� � � ,J�'�� 6. DO NOT ALTER DECK/NG
EtECTR�CAL �` ' SPECIHCATIONS.
` �; � � ''' ���
p LIGHT SETBA'�K LINE i '��
p �uricrior�sox_ � � ,,,-�'� su�srn,w: RS ww,e Rcrhert&Krlstetr Clark
� ,
LINES � `� �` ,,,,.-�' PERMRN.: X aossrr�noo�ss: 16 Patton Circle
WATE:RLWE � �� ; ,,,= ,,�N, X Salem, MA 01970
\\ `'' � Ra � (978j 74f-8'f15
—•—• 6EC'tE EHiE \ �� Dic sntE N_ '
—————SETBACK LINE \ `� D���:
HAC 8,�.�: cel/(800) 615-0271
—Q--o-- FENCEUNE ` ` CHECI�DBY: X �A� � POOLS BY
---- LOT LINE \ �`` � ������ � �'���
_..........._ PIPE LINE �
-•-•--••••••- coNQu�rurtE . � Pg. N.: � SCdle: �/�}"��'-�" TELEPHONEN (800}272-79462
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