29-084 (6) 11 ACREBROOK DR BP-2021-1173
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-084 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:Above ground pool BUILDING PERMIT
Permit# BP-2021-1173
Project# JS-2021-001971
Est.Cost: $9000.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JELLY BELLY'S POOLS & SPAS, INC 126929
Lot Size(sq. ft.): 12980.88 Owner: JENNISON KIMBERLY
Zoning: Applicant: JELLY BELLY'S POOLS & SPAS, INC
AT: 11 ACREBROOK DR
Applicant Address: Phone: Insurance:
P 0 BOX 936 (413) 568-1700 Workers Compensation
WESTFI ELDMA01086-0936 ISSUED ON:4/16/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:ABOVE GROUND 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.
` + ''1 •
2
Certificate of Occupancy signature1' • I 0
FeeType: Date Paid: Amount:
Building 4/16/2021 0:00:00 $40.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
1 °K
File#BP-2021-1173
APPLICANT/CONTACT PERSON JELLY BELLY'S POOLS&SPAS,INC
ADDRESS/PHONE P O BOX 936 WESTFIELD (413)568-1700
PROPERTY LOCATION 11 ACREBROOK DR
MAP 29 PARCEL 084 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid 4
Building Permit Filled out
Fee Paid
Typeof Construction:_ABOVE GROUND POOL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 126929
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
X 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
ia •� , /l�5/at
Sign:ture of Building Official Date
1
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.
RECEIVED 4...
The Commonwealth of Massachusetts APR 1 2 2091 FOR
Board of Building Regulations and Standards
UTYti) Massachusetts State Building Code,78C CMI MUNICIPALITY
USE
E��1z-NOWNSPE TIQ
Building Permit Application To Construct,Repair,Ret�ova�e IVV �sAo 16;�6���a/Ma�•2011
One- or Two-Family Dwelling '
This Section For Official Use Only
Building Permit Number: B iGt. go,p4 17 3 Date Applied:
v tr .24 .r‘i;,
Building Official(Print Name) I Signature ' i L e
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes no Map Num�ar Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required ,t Providedt_ Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: , Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
\f--,Cm*)L Vr\_ -:= c\I-\\= -1 C 1C,•� 1-'1(s rr•rt-\ 0:kC'g:1...
Name(Print) City,State,ZIP
",t-\-•.;c`.-. k 3=• c> .•17-3`.i .1( ),.�J,c,k\\., C(:-V--(f t,L,.c.c.r,
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check aft that apply)
New Construction 0 Existing Building 0 Owner-Occupied ❑ Repairs(s) 0 Aiteration(s) ❑ Addition 0
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ecify:11.4.7 .,, c :c ,-Cc. �,
Brief Description of Proposed Work2: LCz,..S:x.;A- tc , Nx�.�xC,0, C-_ L`-1 ' x ." C:k.1g-:C u'�.. ic(-:,..-ei<
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1. Building '$c; _k (. 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ 0 Standard City/Town Application Fee
C C C J 0 Total Project Costa(Item 6)x multiplier _x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (I-1VAC) $ List:_
5. Mechanical (Fire $
Suppression) Total All Fe
., ._ C._ Check No.J' Check Amount: iffl Cash Amount:
1 6- Total Project Cost: t t 1 p paid in Full D Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
Je\\ \�\2GZ.z.
�� �UC�SC�S Z - HIC Registration Number Expiration Date
HIC Comrifinv Name lir HIC Registrant Name
��p���yPCLaS QC�\-CCr
No.and Street Mnail address
_Wes`ckvt:'Ack >A ,\CXs 2., 4\3 c, a \C:�C)
City/Town,State,LIP Telephone
SECTION 6: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 o e building permit.
Signed Affidavit Attached? Yes No .❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize ���\\ �? �\y -Vo r-C_
to act on my behalf,in all matters relative to work authorized by this building permit application.
y 4 l6l z 1
Print Owner's Wire(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
4ibn 6-Cnn64 _, (--c 18111
Print Owner's or orized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at
www.mass.govioca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
The Commonwealth of iliissuchusetts
L =_ Department of Industrial Accidents
L _;'017s I Congress Street,Suite 100
_
4 f=� Boston.AL-t 0211 f-2017
ww,v.surLss.gov/din
Hurlers Compensation Insurance rAtlidawit:Buildersf('ofttractorxirt:lectriciansei'PIunthrrs.
To BE FILED WITH Tilt:PERMITTING TING AI'i Ift)Rfi'l.
Name
t Information Please Print Leuihtw
7 Mam'e i Hutilat a I.�I'tidllil.,llli+67.Ini11'.7,11 19:1tk _\ ' Q
City/State/Zip: � �'����\( ri1A OAGbS Phone#:
Are wn an etsiliki)tt?Check thr aplrrutrri:ite trot: Type of Iirtojiet1`retitniredf:
1. Knr enkt liecsltnnn:entierParu cruet." 7- j New co nstru ctitm
--D am a Nll tph cttaL1Jatr i?hap and hat WUrLni forme N 8_ Remodeling
any iNu'worker,'ctnp. N ttquirud l 9. Q Demolition
{. I ant a JIUnat'Ho m.a donut all Nutt a n.d1.[No M.irk..."•ctnl4i.amnia:ince mineral
4.0 I ant a tb.!HLhaivinet and 4e ill he hiring contratlut+to tvrndue.i aft Work t n my tnYtaitTl_4_ I will
to D Building addition
tlt,ule that all evatractur.,tither lane%tinkers'counnattatian i tairdrtta:ear axe stout' I I a Electrical repairs or additions
ptupn..ti'r.with no canplusc,3.
1 . Piumhing repairs or addition
i�..�t am a ut�tteal eel lIraetin and t km.:hind the wibt't of ictors tested On the attaLtltd Acct. 110 Roof rCllai3 l
a Them:,:tip-L:vntrsctun haw t�nplt/1,ers atoll haw noire:rs'comp.iirtia:ince.:
6.J We an:a tuatr inili&in and itt.officer,haw catacised alien right of e.c!tamililt NI Slut_c. I4. ter�yr��
t$:!.5t{,1k,antlwaIca.cnut7trltilu)ccs.[ocheMMaara'cretup.inSurntttsequin-c .i QGG\
'Any applitaHt that chef es box s L mint a1.Lr till out the%ca-tion lie&ies show My their tuita st►'otimpessition iHiuiitaluise_
+Ikurtreir tr,rs't tit/eiit,uiit this a8tdat at uldreaiae;t ey,ail doing alt a iota:cad than lluc outside.L'MHiraetvts mum!ail it a ttt11 attid ie it ttttiitatit . _...
t.'untractLns that check the,b it mix attaclr:ti an additional shin t sleuu in ;IT.:na a of flit,ill*-ciintraetur..and Ntate,foible to not t ue.c enimlit,tip.
tutployeeg LI the:.ub-eUrirr,actL7rs haw tvigdu:yccs.tllty mug provide their .aa+rkeia"ulnop.trutite neurcllra_
I ant an employer that is providing svorkers"eampeasuliun insurance far nay employees. Below is the politer and,jab site
information.
Insurance Company Name: W �'t aUti"G�rC e_ tom,jam_ _
Policy#ter Self-ins.Lie.#: J.)( ..) C .��{ \��C i� Expiration Date: 1. , \ \Z\
Jub Site Address: \ tCityoStatedliip: x Pc�ca- eO rk G`Uha2
Attach a cops of the workers'compensation policy declaration page(showing the policy number and expWatiou date).
Failure to secure coverage as required under MGL c. 152.•§25A is a eriinirwi ululation punishable by a tine up to 51,500_P0
and ur one-year intprisoni a nt,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to 525O.il(.I a
day against the%iuiator_A copy of this statement may be forwarded to the Office of Investigations of the DL A for insurance
+.eritecatiiin.
I du hereby"certify under the paint and penalties of perjury that the ittfarmatiun provided above is true and correct.
ii7n.ltur Date: 3/ a 1
Phone w: C.a
Official use only. Do nor*write in this area,to be completed by city or hnsn official
City or Town: Permit/License Ot
Issuing Authority (circle one):
I.Board of Health 2.Building Department 3.C ityTfuwn Clerk 4.Electrical Inspector S.Plumbing Inspector
6.(liter
Contact Person: Phone#:
•'^+`•.'� ^ v cVL I-v.r I I I J.YV.:Yf CO r 141;Jb4 f4046 From:Rosemary Dinatal
�-�1 JELLBEL-01 RDINATALE
A`.r-"R�µ CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYVYYI
�
3/11/2021
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(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WANED, subject to the terms and conditions or 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 License 0 1780862 I CCWiTACT Rosemary DiNatale
HUB International New England PHONE — FAY
96 Shaker Rd iI(NC,No.EKII: ((A/C Ij,k
East Longmeadow,MA 01028 i MSS,Rosemary.dinatale@ihubinternationaLcom
iINSURER(S)AFFORDING COVERAGE NAIC N -
1 INSURER A:Regent Insurance Company 24449
INSURED I INSURER B:Wesco Insurance Company 25011
--- - ---- -----
Jelly Belly's Pools&Spas Inc. 1 INSLIRERC_
PO Box 936
INSURERO:
Westfield,MA 01086-0936
I INSURER E: _
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTIMTHSTANDING 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF MVSURANCED y ND POLICY NUMBER t POLICY EFF POLICY EXP }
A X COMMERCIAL GENERAL LIAaMJTY (Mq(IrDD/YYYY) rNMtiDDtYYYY1€ LIMITS
I I EACH OCCURRENCE $ 1,000,000
I CLAIMS-MADE X OCCUR BPK00047II7-01 7/1/2020 7/1/2021 1 DA GETT R oNNTED eat I 100,000
I HIED EXP(Any Noe person) S 5,000
1 PERSONAL 8 ADV INJURY I 1,000,000
ri
GEM.A I IGENERALAGGREGATE $ 2,000,0D0
�LIOY I I Loc i I PRODucTs.couProPAGG $ 2,000,000
OTHER: I i $
AUTOMOeI.E UAUIJTY i CO SINGLE UNIT $
---IANY AUTO I
EDGILY INJURY(Per person) 5
CANED ?SCHEDULED _._.-.._
AUTOS ONLY i AU TOG ( I I
BODILY INJURY(Par aCCidlMll S
HIRED I NON ownFp I PROPERTY DAMAGE
AEITOE ONLY I AUTOS ONL! (Par accident) S
I
UMBRELLA LIAR ' OCCUR I EACH OCCURRENCE I
EXCESS LIAR 7 CLAIMS-MADE r
' I AGGREGATE $
DED I RETENTION S t I $
B WORKERS COMPENSATION i STATUTE t ER
ANO EMPLOYERS'UABILRY I X PER X 1 arm-
STATUTE�PR�OPRIETpO�RjtIPARTNEREXECUT1tj YIN I IANVC1477907 7/1/2020 7/1/2021 I } 1,000,000
figa(RrMEritg EXCLUDED? N I NM' 'El-EACH ACCIDENT 1,000,000
M a Nn) t I E.L.DISEASE-EA EMPLOYEE$
DE CRIPTION OF OPERATIONS below 1,000,000
I
I E.L.DISEASE-POUCY LIMIT S
I
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Kimberly JMIISOn THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
11 Acebrook Drive
Florence,MA 01062
AUTHORIZED REPRESENTATIVE
i
I i/ /
ACORD 25(2016/03) ®1988-2015 ACORD CORPORATION. Al)rights reserved,
The ACORD name and logo are registered marks of ACORD
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