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43-105 (4) BP-2022-0123 440 WESTHAMPTON RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 43-105-001 CITY OF NORTHAMPTON Permit: Swimming Pool PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2022-0123 PERMISSION IS HEREBY GRANTED TO: Project# INGROUND POOL Contractor: License: Est. Cost: 113636 AQUA POOL and PATIO CO Const.Class: Exp.Date: Use Group: Owner: BUCKLEY-FORTIN, JACOB & FAYE STEPHENS Lot Size (sq.ft.) Zoning: WSP Applicant: AQUA POOL & PATIO CO Applicant Address Phone: Insurance: 53 NEWBURRY RD (860)623-8374 2093838123 EAST WINDSOR, CT 06088 ISSUED ON:02/14/2022 TO PERFORM THE FOLLOWING WORK: 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: Gas: Final: Final: Rough Frame: Rough: Fire Department Driveway Final: Fireplace/Chimney: Final: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. (� Signature: ! I y . 55-01 Fees Paid: $75.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner I I . fr-TE-C-P1 The Commonwealth of Massachusetts F E 8 ,, k'Y; Board of Building Regulations and Standards 8 2022 NIUNI0'AI,ITY L. Massachusetts State Building Code, 780 C USE OF n s I Building Permit Application To Construct,Repair,Renovate4ilalgO/Meat- ; Acvised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: /!f-A,)• C'I) Date Applied: . .2 ? , Building Official(Print Name) Signature `V 4a SECTION 1:SITE INFORMATION 1.1 Property Address: 01.2 Assessors Map&Parcel Numbers 140 w<s�>`t..�.,,��., 1.1 a Is this an accepted street?yes; no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: ! 32 aci-c� Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) • Front Yard Side Yards Rear Yard 4 Required Provided ! Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Publics Private 0 • Zone: _ Outside Flood Zone? Municipal Q On site disposal system Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: N µK �-tp. Cr l 0 6 f= S�p�x �,5 lP Name(Print) City,State,ZIP 440 W 2S+l ,a_ 14. P-4 $n g-C 4 2- ct a q S 41.c p tte i)I 6wL-41./; l- (,"'-1. No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 4( Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition ❑' Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: 1 J I SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ i p 1. Building Permit Fee: $ Indicate how fee is determined: CI Standard City/Town Application Fee 2.Electrical $�,SUo e S 0 Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ r,. /ek 2. Other Fees: $ 4.Mechanical (HVAC) $ t,,,'14 List: 5. Mechanical (Fire 1, I Suppression) $ v''#`a Total All Fees:$ Check No. Check Amount: Cash Amount: i 6.Total Project Cost: $ 11 L3 ElPaid in Full 0 Outstanding Balance Due: 1 1 1 i l I 3 -0 i f SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) I License Number Expiration Date Name of CSL Holdr I List CSL Type(see below) No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State,ZIP R _ Restricted 1&2 Family Dwelling 1 M Masonry RC Roofing Covering r WS Window and Siding SF Solid Fuel Burning Appliances 1 I Insulation Telephone I Email address D Demolition 5.2 Registered ome Improvement Contractor(HIC) I: 3 9 I -7,122/2 3 Lt�t 8t9� + c. �-c o I L t HIC Registration Number Expiration Date HIC Company Na re or HIC Re 'strant Name c3 'NJ ChI rV vt � �KL�t�t cm/S- G{ 1e 'QPLt a vY eo01_ C1 No.and Street Y Email address Ect 5)- W, RS"' , Gfi V.6 o8`d kbo- 623 - 9Y8i City/Town,State,fZIP 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 of the building permit. Signed Affidavit Attached? Yes No 0 1 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT i I,as Owner of thl subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. 1 Print Owner's Nam- (Electronic .. :_� Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION 1 :y entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained'in this 4pplication is true and accurate to the best of my knowledge and understanding. { Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: .' owner who obtains a building permit to do his/her own work,or an owner who hires an unregiste ontractor egis - .. '.- _•- ..II' II. . ...., •,tractor(HIC)Program),will not ha a arbitration program . .ranty fund under M.G.L.c. 42A.Other important information on the HIC Program can be found at www.mass.gbvf /oca . . -+ •- i e Construction Supervisor License can be found at www.mass.gov/dps 2. When substaai�tial work is planned,provide the information below: Total floor area(dq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area sq. ft.) {.. Habitable room count Number of firepl ces i,I A Number of bedrooms Number of bathrooms i,,,d is Number of half/baths • Type of heating system w/ A Number of decks/porches _ Type of cooling system c- 9 it Enclosed Open 3. "Total Project'Square Footage"may be substituted for"Total Project Cost" 1 Site Overview Created @Jan 27, 2021 6:15 PM ._ Tags • i _ _ :, _..„ �. i i s TM t > 1 a 1 ''I t t 1 r•---� t y; f Usable , !;-ores) (�12 acres) , 1�P \ ' 77*----' '-'"'"1 \ "V. to-;v4ii A 32 AC. K S Site Overview 1 . t 't 1 [ The Commonwealth of Massachusetts •a ft Department of Industrial Accidents • 1 spA _.;-11;f e 1 Congress Street,Suite 100 �„� Boston,MA 0211,-2017 a�,�iv `. I .ntass.go�/ninon f kerst Compe nsation ensation Insurance.16ff- imt it:l3uildtrs't'otttractorstElectricittnsrl'luulbeh. TO 11E 1•'I1.1.:1)?VI1.11'VHF:PERM ITIIM;Al"11imam I ' Atlttlicatlt lnfttrutatio* Please Prin Leeibls Name e. S �Q kV-14./3 • Address: ' 10° W-e-t+ - Ne A------- V---' orcLZ , City/State/Zip: ►J -L 4...e tom, t J4''A Phone#: 5-b k-S 9-z- a `I q r __. Are'tnu an employer?Cheek the appmpronte heal Tvpeof project( aired): 1.01 aunt a entph»'tr with ,_...._ «employes(full miler a. th Nevi cunstru ion C31 ant a sole pcupnctur or pxutaet*ip and have no evyatokees working for me in H.L.3�..f Remodeling sale easicic .[u r.:wort c 'cotrrpk insurance required.) 01 ant a hora..soantr doing all work thyself.No w�o/has'etetr.rrbt rrtt1�e tequiral' 9. 0 Demolition _ 4,FL1.1 h ant a omwaner and lee iti be hiring ountrrsturs to conduct all work on net°property. 1 will )D 0 Budding add 'on ' cumin:that all ccryttr•.tahurs cithrt lw.c§r:rrltera.'eat rpc1t alien iarwanix or an:hole I I.0 Electrical re. ins or addition proprietors with no employees. 12.0 Plumbing re•.; rs or addition:, 50 1 am a general contractor and I h v'c hired the sub-euntractars listed tin the attached diem- ' 130 Roof repairs. Thine sub-contractors have employee-sand have Norte 'comp.imttrrrue. _ 6.0 We an:a rorpornturn and its uffittrs base.sencist:d their right of csintgrtitm per Wit.c. 1 .UCnitt't 152..a1t41.and we have no employees.[No workers'eiartp.insurance required.[ 'Any apptteaat that cheeks bass 01 must also till VOL the section below show Mg their workers•compensation pule.,information. *Homeowners who submit this attkdasir indicatittc they arc doing all work and then hire outside crab.:tors must submit a new uffrct v it iott ng tuck t •Contractors that check this boa must ate loin d an additional sheet show ins the name of the sub-contr.etors.and state altetinr or not those fifties hsA. empluyee.:. if dx sub-contractors lame onpIuy ten.they natal provide.their workers-amp.pokey number. I ant an employer that is providing workers'compensation insurance for my entptoyees. Below is the policy any/job site information. Insunuice Company Nance: . c _ 0..-/1 C. K I _____ Policy#or Self-ins.Lie.#: 1 Expiration Date: Job Site Address: CitviState:Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and Cl,iratiod date). Failure to secure coverage as required under MGI c. 152,*25A is a criminal violation punishable by a fine u• to S F 5D0.UU antl'or one-year imprisonment,is well as civil penalties in the farm of a STOP WORK ORDER and a fine of' p to S25{l.00 a day against the sviolator.A copy of this statement may be forwarded to the Office of Investigations of the DIArise.insurance coveraur terificatiun. I du hereby certif•under the pain nd penalties a/perjury that the information provided above is true❑ndk karma. ,. - Sn nature: ` \' Date: 0 , a I I � Phone,w: � 4- It-Z— et q ti s Official use only. Do not write in this area.to be completed by city or town official City or Town: Permit/License tt Issuing Authority(circle one): I. Board of Health 2.Building Department 3.City/rows Clerk 4.Electrical Inspector 5. Plumbing lnspectur 6.Other C'outset Person: • Phone#. 7 t City of Northampton - " r " Massachusetts ��5 r%r *bt -G. -. 4. -- , �" ` DEPARTMENT OF BUILDING INSPECTIONS ? ,, 212 Main Street • Municipal Building %) C?' \\ o„Y.' ,Vrrg/ Northampton, MA 01060 `:5't y 7y^\` HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT I. (insert full legal name), born (insert month, day, year), hereby depose and state the following: I 1. I am see 'ng a building permit pursuant to the homeowners' exemption to the permit requirements of the Massachu etts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a parcel of I nd to which I hold legal title. 2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners'exemption, does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3. i 1 3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2: Person(s who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intend d to be, a one-or two-family dwelling, attached or detached structures accessory to such use and/or f rm structures.A person who constructs more than one home in a two-year period shall not be considers'd a home owner. 1 4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualify for and will apide by the Massachusetts State Building Code's requirements for the supervision of the project or work on my parcel, I am not engaged in construction supervision in connection with any project or work involving constructs' n, reconstruction, alteration, repair, removal or demolition involving any activity regulated by any provision f the Massachusetts State Building Code. 5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my parcel, I acknowledge that I am required to and will act as the supervisor for said project or work. Signed under the pains and penalties of perjury on this day of k t v t&1Vv) , 20± ' i i (Signature) �"--Th AQUAP-1 OP ID: ME A. RL'' :' CERTIFICATE OF LIABILITY INSU DATE(MM/DD/YYYY) 01/26/2022 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 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 Marnie Evans Evans, Pires&Leonard 121 Roberts Street (NC,No,ExtY 860-289-6816 FAX No); 860-291-8848 East Hartford,CT 06108 E-ML ADDRaEss:mevans@evans-insurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Valley Forge Insurance Co. 20508 INSURED Aqua Pool&Patio,Inc. INSURER B:American Casualty Co. 20427 53 Newberry Road East Windsor,CT 06088 INSURER C: INSURER D: j INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. NOTWITHS,ANDING 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 COND TIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF I POLICY EXP U�{ _- LTR TYPE OF INSANCE INSR WVD POLICY NUMBER (MM/DD/YYYY){(MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY 7012210019 02/01/2021 02/01/2022 DAMAGE SET(Ea occurrence) $ 300,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L.AGGREGATE LIMIT APPLIES PER: :PRODUCTS-COMP/OP AGG $ 2,000,000 7 POLICY X PRO- JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ A X ANY AUTO 7012210036 02/01/2021 02/01/2022 BODILY INJURY(Per person) $ ALL OWNED J SCHEDULED AUTOS ( AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS 1 NON-OWNED PROPERTY DAMAGE �i AUTOS (PER ACCIDENT) $ 1 $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE :AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- 0TH- AND EMPLOYERS'LIABILITY X TORY LIMITS ER B ANY PROPRIETOR/PARTNE►i/EXECUTIVEY/N 7012248009 02/01/2021 02/01/2022 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERAT'ONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) RE: Jacob Buckley-Fortin & Faye Stephens 246 Cardinal Way, Northampton, MA 01062 CERTIFICATE HOLDER CANCELLATION NORTH02 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE • THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Northampton ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Buildiig Department 212 Main S reet AUTHORIZED REPRESENTATIVE Northampton, MA 01060 '—'1 UjtW. Wh_ ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) I The ACORD name and logo are registered marks of ACORD I Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation r5 Registration: 113981 AQUA POOL &PATIO, INC. Expiration: 07/22/2023 C\ 53 NEWBERRY RD _ E WINDSOR, CT 06088 -r, C Update Address and Return Card. / -4. Office of Consumer Affairs&Business Regulatio' HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation � . before the expiration date. If found return to: C J. Registration_ Expiratiofl.. Office of Consumer Affairs and Business Regulation �� 113981 07/22/20 1000 Washington Street -Suite 710 -.) `AMA POOL 8 PATIO, INC. Boston,MA 02118 /� n rN MICHAEL A.GIANNAMORE V signature Undersecretary i i