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a�: ��:�� ■F s` a K4 `■ rr/^�__
DATE(MMiDD/YY)
04/04/01
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
INSURANCE CENTER OF N ENGLAND ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
D/B/A SULLIVAN INSURANCE ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P O BOX 1180 COMPANIES AFFORDING COVERAGE
W S PFLD MA 01090 COMPANY
A CNA/CONTINENTAL (SURPL SVCS)
ENSURED
COMPANY
TEDDY BEAR POOLS INC B
ATTN: TED HEBERT ! COMPANY
41 EAST ST C
CHICOPEE FALLS MA 01020 COMPANY
i D
COVERAGES
THIS 1S 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.
CO ! TYPE OF INSURANCE POLICY NUMBE R I POLICY EFFECTIVE POLICY EXPIRATION LIMITS
.TR DATE(MMiDD/YY) DATE(MM/DD/YY)
GENERAL LIABILITY 12025064167 0 4/0 1/01 f 04/01/02 GENERAL AGGREGATE s2, 0 0 0 , 000
XX COMMERCIAL GENERAL LIABILITY PRODUCTS•COMP/OP AGG!$2 r 0'0 0, 000
I CLAIMS MADE C OCCUR I ! PERSONAL 3 ADV INJURY '$1 r 000, 0 0 0
OWNER'S 3 CONTRACTOR'S PROT. I j EACH OCCURRENCE I$1, 000, 0 0 0
FIRE DAMAGE(Any one fire) $ 50, 0 0 0
MED EXP(Any one person) 1$ S, 000
AUTOMOBILE LIABILITY
ANY AUTO COMBINED SINGLE LIMIT $
ALL OWNED AUTOS
--- BODILY INJURY
SCHEDULED AUTOS (Per person) ($
HIRED AUTOS BODILY INJURY
NON-OWNED AUTOS (Per accident) $
I
I
PROPERTY DAMAGE $
GARAGE LIABILITY AUTO ONLY•EA ACCIDENT:$
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE 'S
EXCESS LIABILITY 2025064248 04/01/01 04/01/02 EACH OCCURRENCE .$1, 000 , 000
X UMBRELLA FORM AGGREGATE $1, 0 0 0 , O O O
OTHER THAN UMBRELLA FORM $
WORKERS COMPENSATION AND WC10 8 0 018 2 7 5 04/01/01 0 4/0 1/0 2 X `N S I T u• TH.
TORY LIMITS ER '
EMPLOYERS' LIABILITY
_ _EL EACH ACCIDENT $ S00 , 000
THE PROPRIETOR,' INCL EL DISEASE-POLICY LIMIT ' $ 500 , 000
PARTNERS,EXECUTIVE '—
OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE $ 500 , 000
OTHER
ESCRIPT70N OF OPERA TIONStOCATIONSIVEHICLES/SPECIAL ITEMS
ERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
TO WHOM IT MAY CONCERN EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
20 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY X)ND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENT TTVE
`''�,,__ NJ F
X � ( 6,ORPORATION 1988
.ORD ZS-S (1,'95)
��ttAA1PJ0
�O a -
� 6 �laisarknsctta'
DEPARTMENT OF BUILDITIG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 0.
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(A
(licensee/permittee)
with a principal place of businessJresidence at:
Wo0-0 t.ia—o -Dz F MA (phone#) L-1 -5�'1'3'`�Z^
(street/city/statdziP)
do hereby certify, under the pains and penalties of perjury, that:
t e I a an employer providing the following worker's compensation coverage for my
pm loyees working on this job:
mpany) (Policy N (Expiration Date)
am a sole proprietor, general contracoo or homeowner(circ one) and have hired
the contractors listed below who have the fo or mpensation policies:
ao�5°L.`s
(Name o ontractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional shoo if n6ocna y to inetude kdbrmstioa pertaining to all ooatradon)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that wbilo homcown=who employ person:to do msinzenaneo,c=st a oa or repair work on s dwelling of
not mote than three units in which the homeowner resides or on the grounds appurtenant thereto are not generally mnlidcmd to be
employers under the workces oompe=4m Act(GL152,ss 1(5)j application by a homeowner for a lice—or Permit may cvil r the
legal stawa of an employer under the Worke s Compeosation Acl.
I underst=d that a copy of this statement may be forwarded to the Department of Kiel A=dm&Offioe of Imauaooe for the
coverage verificatioo and that failure to scaue coverage undor section 25A of MOIL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to$1,500.00 and/or kgxiso�of up to one year and civil penalties in the form of a Stop Work Order and a
film of 5100.00 a day againA ma.
/ For iqur�l use only
S II Permit Number
z t l a WO Lot#
Signature ofLicensee/Permi e
SECTION 8.CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: TC 0 A y Q&Apt,
License Number
4L £JokT ST C�Ay-0n�c _ M�
Address Expiration Date
Signature Telephone
Not. i ,.._... . FEE Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.''c. 152, §25C(6))
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....... 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
4
59CTIQN 5- P _PBQP Oftl( I appllgaW
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks
[ ] Siding[ ] Other [dJ
Brief Description of Proposed Work:
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes ��No
Attached Narrative❑ Renovating.unfinished basement Yes .,—No
Plans Attached Roil❑• Sheet❑
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. Mascheck 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 7'a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES-FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize r - 4oD�S to act on
my behalf, in all matters relative to work authorized by this building permit application.
lAlt-t. W— 5 I Zt to
Signature of Owner Date
!, ✓t-� M . �iC,.rw�Uo y as Owner/Authorized Agent
hereby declare that the statements and info mation on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
M/;,el,y M - Kr- r, jeo
Print Name
Signature of Owner/Agent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage 1 �5 •� 2
Setbacks Front DO ✓�
Side L: R: L: y� R:
t �
Rear 2®5
2,S
Building Height
Bldg. Square Footage a 2 Lt p % O
Open Space Footage %
(Lot area minus bldg&paved
arkin
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW f YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES ✓ ( w"-
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained /� , Date Issued:
C WM —ML Ttn XT- Wr-- 0%0 OOT NESS 0-t- A-. Goo N[r rVG "NOT" D%O NOT C.""
C. Do any signs exist on the property? YES NO (3,&F re 2
✓
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property?YES_
No
IF YES, describe size, type and location:
a
t..
QEC E o orthampton
Bu i Department
MAY 2 1 2041 ain Street
o m 100
�I mp on, MA 01060
DEPT Of M 2f2f JTtT l 0 Fax 413.587.1272
NO
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property hectlbn iC
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1"[ VybD�(Jl.�f�iN'�
1 orev�ue, M O 1 O to a
Eitn St C>i'strict ,;
SECTION 2'- PROPERTY OWNERSHIP/AUTHORIZED AGENT`'
2.1 Owner of Record:
Name(Print) Current Mailing Address: N13 - S�7 _ 314 DL CND
IMIJ Telephone 413 - to v5 — 9'30 b �e L
Signature "'
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
-SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing �3(o Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4 + 5) o�.) oon- °b Check Number
This,Section F'or Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date'',
File#BP-2001-0961
APPLICANT/CONTACT PERSON KENNEDY MARK&MARY JO
ADDRESS/PHONE 74 WOODLAND DR (413)587-3142 Q
PROPERTY LOCATION 74 WOODLAND DR
MAP 35 PARCEL 275 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out. _
Fee Paid 410 415
Typeof Construction: CONSTRUCT 18 X 36 INGROUND POOL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
f Approved as presented/based on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § w/ZONING BOARD OF APPEALS
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 Co ission Permit from CB Architecture Committee
of
O'5�_ 40
Signature of Building O cial 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.
WOODLAND DR BP-2001-0961
GIS#: COMMONWEALTH OF MASSACHUSETTS
t CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Cate og ry: Inground Pool BUILDING PERMIT
Permit# BP-2001-0961
Project# JS-2001-1725
Est.Cost:$22000.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sq.ft.): 67953.60 Owner: KENNEDY MARK&MARY JO
Zoning: SR Applicant: KENNEDY MARK & MARY JO
AT. 74 WOODLAND DR
Applicant Address: Phone: Insurance:
74 WOODLAND DR (413) 587-3142 ()
FLORENCEMA01062 ISSUED ON:51241010:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 18 X 36 INGROUND POOL
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
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 Si nature:
Fee T e: Recei t No: Date Paid: Check No: Amount:
Building 5/24/010:00:00 6686 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
NNW