44-123 (2) 1123 FLORENCE RD BP- 2010 -0978
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map:Bloc 44 -123 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2010 -0978
Project # JS- 2010 - 001444
Est. Cost: $29500.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: LANDMARK POOLS 113833
Lot Size(sq. ft.): 59677.20 Owner. SIR.ACO SANDRA J & DEBORAH A BLUME
Zoning: SR(100 )//WSP II Applicant: LANDMARK POOLS
AT. 1123 FLORENCE RD
Applicant Address: Phone: Insurance:
P O BOX 450 (860) 550 -0402 () Workers
Compensation
VERNONCT06066 ISSUED ON :51712010 0:00:00
TO PERFORM THE FOLLOWING WORK.- INSTALL 16 X 35 INGROUND POOL
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House # Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 5/7/2010 0:00:00 $60.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
File # BP- 2010 -0978
APPLICANT /CONTACT PERSON LANDMARK POOLS
ADDRESSIPHONE P O BOX 450 VERNON (860) 550 -0402 ()
PROPERTY LOCATION 1123 FLORENCE RD
MAP 44 PARCEL 123 001 ZONE SR(100) //WSP II
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out
Fee Paid
Typeof Construction: INSTALL 16 X 35 INGROUND POOL
New Construction
Non Structural interior renovations
Addition to Existing _
Accessory Structure
Building Plans Included:
Owner/ Statement or License 113833
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
a�
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
City of Northampton
Building Department
212 Main Street
10 Room 100
tifv,� Mort ampton, MA 01060
phone. -413 -5 7 -1240 Fax 413 -587 -1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION <1 -SITE INFORMATION
1.1 Property Address This section to be completed by office
Map ' Lot Unit
113 V
rb 2'✓) <�, 0M zone" Overlay 01 triet
Etffi St, DistrlcY CB District,
SECTION -2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
Name (Print) Current ailing Address:
P l�
Telephone
Signature
2.2 Authorized Aaent: p '
Name (Print) Current Mailing Address:
e
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building �`y- —� (a) Building Permit Fee
2. Electrical (� / (6) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1 +2+3+4+5) Check Number
This Section For Official Use Onl
Date
Building` Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
y
Section 4 ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size J 7S
I I
Frontage
Setbacks Front
Side L• R: L . . ,_.,_.�.,._,.,_ .= R :=
Rear b 6
Building Height
Bldg. Square Footage % r? q % , ! I
Open Space Footage %
(Lot area minus bldg & paved
par
# of Parking Spaces - --- -
Fill:
volume & Location
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DON7 KNOW 10 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 D ONT KNOW YES 0
IF YES: enter Book r Page Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW W YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained 0 , Date Issued
C. Do any signs exist on the property? YES ® NO
IF YES, describe size, type and location:��
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
v
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all auailcable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[Z] Siding [O] Other [19]
Brief Description of Proposed
Work: 1 i tS lc I I 3
Alteration of existing bedroom Yes_ No Adding new bedroom Yes _ No
Attached Narrative Renovating unfinished basement Yes -- No
Plans Attached Roll - Sheet
art
Of -k &M 71, ififfifim W615 S'
a. Use of building: One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION - TQ BE COMPLETE[) WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT'
A / `»
I �� E � - J t-�,�C _ _ � �'��c �,c',c/ f l / , as Owner of the subject
property
herebyauthorize ET /m -1/0
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Sig under the pains / and penalties of pedury.
✓IC'�JC�/E�iT � LJL LLY�Z�.�
Print Name
Signature of Owner/Agent D e
r
SECTION 8 - CONSTRUCTION' SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
8.iate ;Ntl `" .gip' r'v i t a 3 NM Not Applicable ❑
Company Name Registration umber
�� n
Address // Expir i a
tf, "lo Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § -25CM)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... 10 No...... ❑
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, Provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there
is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm
structures. A Person who constructs more than one home in a two -year period shall not be considered a homeowner
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official that he /she shall be
responsible for all such work Performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, You may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
The Commonwealth of Massachusetts
Department of Industrial Accidents -
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass gov /dia
- Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumb.ers
Applicant Information Please Print L �blv
Name ( Business /Organizationandwiduai): J 17' , ,k, S Lic
Address: P(2 fl o &?K qsJ
e
City /State0p: Vc On r L CL44" Phone. #:
Are you an employer?. Check the appropriate -box: Type of project (required) /'
1. I am a employer with 4._ E] I am a general contractor and I '
employees (fall and/or part time).
« have hired the sub- contractors 6. [ New const<vction
2.0 I am a sole proprietor or partner- listed on the attached sheet 7. Remodeling
ship and have no en7Ioyees These sub - contractors have. .8. Demolition
working for -me in any capacity. employees_apd Iz_aye wod='
[No worknn COMB. inSUra�nCe- _. cQnp• t3 - _2 aeon
require&j 5. Ej We are a corpoiation and. its 10 Q Electrical repairs or additions
officers bave Exercised their mg epaizs
3. or additions
0 I am a homeowner doing all work r 11. Plumb' r
myself- [No workers' comp. right 6f exemption per MGL 12. Roof sus
rep
insurance r t c. 152, §1(4), and we have no
employees: [No workers' 13.0 Other
comp. insurance regtiired.j.
'Any applicant ibat chwia box f1 nsast also Ell out the section below-showing dicirworlaws policy infomratiorL
r Homeowners who submit this afiidavit.indicating they are doiag all work and then bore outside cont=on must submit a new.affidavit indicating such.
:Cormactors that check this box m=-attached m additional sheet showing the name of the sub-conhaetm and state whe —or not thaw entities have
employees..lf the sorb -ronft t rs have employees, they must provide their work=' comp. pobcy number.
raw an employer that isproviding workers' compensation insurance for my employees Below is the policy cud job site
information e -
Insurance Company Name: a� t U, �� �1� ' S . r -�1��1 �C
IS
Policy # or Self- -ins. Lic. #: MFI� l I[ / , . k)'(
Expirati Date:
Job Site Address: City/StafxlZtp: -�t �r.: - M
Attach a copy of the workers' compensation policy declaration page•(showing the policy number and ezpirahon date).
Failure . to' secure covers_ . _ . a
ge - as required undci.Sectrtin 25A ofMGL c: can Iead to the imposmon of crimmil 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 fum
of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investisatrons the b for insurance coverage vtsiification
I do Hereby c the pares and p altres of penury that the information pm . ' ed_abov L � _andcurr ecx
- -
_ - - ....._ _ _ate- . - `�— � • .� /.C� _
.Si tore ,
Phone 4:
Fth only. Do not write in this area, to be completed by city or town offwjaL
n- Permit/Llcense #
Issuing ority (circle one):
Health 2. Building Department 3. City/Town Clerk .4. Electrical Inspector 5. Plumbing Inspector
son: Phone #•
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two family
dwelling, attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two -year period shall not be considered a
home owner."
The building, department for the City of Northampton wants person(s) who seek to use
the home owner exemption, - to act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires that the.building department be called to
inspect work at various stages, which include foundation /footings (before backfill),
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these insuections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
�ermits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DIELAY the project until such time as the proper permits and inspections are
made
I, understand the above.
.(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to
Date
Address of work
location
04/30/2010 FRI 8:24 FAX 860 875 0521 0001/001
ACORD CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDDYYY)
� 1 04130
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Dowding, Moriarty S Dimock Inc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
139 Union Street ALTER THE COVERAGE AFFORDED BY THE POLICES BELOW.
Rockville CT 06066
Ph one:860 - 8 7 5 -2523 Fax: 860- 875-0921 INSURERS AFFORDING COVERAGE NAIL•
INSURED __ -- INSURER HARLBYSVILLE INS
ENSURER B: WWCO INSURAN(M 00.
Landmark, Inc. i Landmark INSURER c
Pools, Inc.
190 Tunnel Rd. INSURER U.
Vernon CT 06066 - --
INSURER [:
COVERAGES
THE POLICES OF IN SURANCE LISTED BE HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTYVITI STANOING
ANY REOIMtEMENT. TERN OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO VMICN THIS CERTFICATE MAY BE ISSUED OR
MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, OCCLUSIONS AND CONGITIM OF SUCH
POLICES. AGGREGATE LIMITS SHONAV WAY HAVE BEEN REDUCED BY PAID CLAIMS,
LTR INSURANCE POLICYMJMDEpt DATE a� MND 10N' r_ LRBTS
GENERAL LIABILITY EACH OCCURRENCE 5$1,000,000.
A X COMMERCIAL GENERAL LIABILITY MPA1M316I 02/18/10 02/18/11 PREMRSESrKe) = $100,000.
CLAIMS MADE ® OCCUR MED EXP (Arq one perms) 8$5,000.
PERSONAL S AM INJURY S$1,000,000.
- GENERAL AGGREGATE s $2, 000, 000.
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG s$2,000, 000.
POLICY X JCCC L.00
AUTO LIABILITY COMBINED SwGLE S 31,000,000.
A ANYAUTO BA3243161 02/18/10 02/18/11 J E°°° ` a° ` d)
ALL OWNED AUTOS
BOOBY MUURY =
X SCHEOULEDAUTOS (perWWA)
X "(RED AUTOS
BODILY MARY =
X NON-OWNED AUTOS IPa aoddo -Q
_..
PROPERTY O oAMAGE S
GARAGE LIABILITY AUTO ONLY -CA ACCIDENT S
ANY AUTO OTHER THAN EAACC S _..
AUTO ONLY: AGG S
EXCES$IUMBRELLA LIABILITY EACH OCCURRENCE s$2,000
A X OCCUR -J CLAANSMADE SElM3161 02/18/10 02/18/11 AGGREGATE s32,000,000.
DEDUCTIBLE :
RETENTION S S
WOMM COMPENSATION AND TORY LBIITS I X ER
H E>r YPRO R IETO �Irr
ANY PROPRIETOWPARTYER/EIfECU ►NE WWC3008803 02/18/10 02/18/11 E.L. EACHA000ENT :$500,000.
OFFICERIMEMBER EXCLUDED? WESOO INSU MCE CO . E L DISEASE - EA EMPLOYEE $3500,000
.
m w, aeeo be ulcer
. IALPROVBSIONSbelow E.L. DISEASE - POLICY LIMIT $ $ 00, 000.
OTHER -T
DESCRIPTION OF OPERATIONS I LOCATIONS I VMCM3 J EXCUUSIONS ADDED BY EMORSEVVIT I SPEGAL PROVISIOla
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ASM DAD POLICIES BE CANCELLED BEFORE THE EXPRA
DATE TDI JUW TIE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFCATE HOLDER NAMED TO THE LEFT. BUT FAE.IIRE TO DO SO SHALL
Deborah Blume
1123 Florence Road IMPOSE NO OBLIGATION OR LIAMUTY OF ANY K UPON THE INSURER, ITS AGENTS OR
Florence MR 01062 REwAEaENTAm1�
AUTHORIZED REPRESENT
GIYA
ACORD 25 (2001108) O ACORD CORPORATION 19$$
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