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18C-113 (3) BP-2022-0403 186 JACKSON ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 18C-113-001 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-2022-0403 PERMISSIONISHEREBYGRANTED TO: Project# ABOVE GROUND POOL Contractor: License: Est. Cost: 7099 Const.Class: Exp.Date: Use Group: Owner: TRUST PHILLIP AND MARY JOHSTON Lot Size (sq.ft.) Zoning: URB Applicant: TEDDY BEAR POOLS & SPAS Applicant Address Phone: Insurance: 41 EAST ST (413)594-2666() WC8665063 CHICOPEE, MA 01020 ISSUED ON:04/22/2022 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: >2 . 5%5. Fees Paid: $40.00 212 Main Street,Phonc(413) 587-1240,Fax:(413)587-1272 Office of the Building Commissioner (7 , y,The Commonwealth of Massachusetts APR 1 g 2022 Boird of Building Regulations and Standards FOR ' Massachusetts State Building Code, 780 CMR MUNICIPALITY r i USE ` ,,r�.T oFl3 g friFT4A0lication To Construct, Repair, Renovate Or Demolish a Revised Mar 2011 N,nnTNAMPToN,MA°lock One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: �6P-22,40.> Date Applied: 4/I� /Coss /712 Li-ZI -ZOZZ Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessoxs Map&Parcel Number 1 186 Jackson Street g(v_ `y 1.1 a Is this an accepted street?yes no Map Number Parcel lV tuber 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq II) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard 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: 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: Adia Johnston Northampton, MA 01060 Name(Print) City,State,ZIP 186 Jackson Street (413) 210-94Q 610 "a110)Sifl ith I (011 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) it New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other Q✓ Specify: Pool Brief Description of Proposed Work2: Above Ground Pool 1 SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ 0 Standard City/Town Application Fee 0 Total Project Cost3(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: , 5. Mechanical (Fire $ Suppression) Total All Fees: 7099 Check No.�Z7 Check Amount: - Cash Amount: 6.Total Project Cost: $ 0 Paid in Full 0 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 I&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(MC) 111889 02/07/2023 Teddy Bear Pools & Spas HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 41 East Street No.and Street Email address Chicopee. MA 01020 413-594-2666 City/Town, State,ZIP 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 0 No 0 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 Teddy Bear Pools & SDas to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(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. Stephen Otto 4/3/22 Print Owner's or Authorized 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.gov/oca 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"may be substituted for"Total Project Cost" The Commonwealth ofMassachusetts f, Department of Industrial Accidents m911f1 1 Congress Street,Suite 100 1.##: Boston,MA 02114-2017 "i = ;. �: i,, www.trrass.gov/dia .. Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Phnnbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organi'ation/lndividual): Teddy Bear Pools & Spas Address;41 East Street city/State/lip:Chicopee, MA 01020 phone#:413-594-2666 Are you an employer?Check the appropriate box: Type of project(required): 1;9✓ I am a employer with 100 employees(full and/or part-time):* 7. El New construction 2.1:I I am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling any capacity.[No workers'comp.insurance required.] iT�I 3.[j I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9 1 1 Demolition 10 []Building addition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11..0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.DRoof repairs These sub-contractors have employees and have workers'romp.insurance.T 6.0 We area corporation and its officers have exercised their right of exemption per lvi(iL c. 14 Other P0OI 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company N ame:HUB International New England Policy#or Self-ins.Lie;.#:WC 8665063 ._� Expiration Date:04/01/2023 186 Jackson St Northampton, MA 01060 Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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 fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Stephen Otto 4/3/22 Date:.. _..._._. Phone#: 413-594-2666 Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3,City/Town Clerk 4.ElectricaI Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone# , --"" 1 TEDDBEA-04 MPROULX AC CERTIFICATE OF LIABILITY INSURANCE DATEIMMl00lYYYY) �'""�- 3/2412022 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 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 1 C TACT HUB International New England i PANE 1 FAX LOX,N&Extt_ I(Mc,no►:(413)731-9639 j_A DRESS: INS iREPHALAFFORDING COVERAGE NAME_..--.. INSURERA:All America Insurance Company 20222 INSURED INSURERa:Central Mutual Insurance Company .20230 Teddy Bear Pools Inc. INSURER c: 41 East St INSURED: Chicopee,MA 01020 . ;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. 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. IL SCR TYPE OF INSURANCE ADDL p SUBR p POLICY NUMBER POLICY EFF POUCY EXP 1 LIMITS 1MM(DDNYYY)r(MWDDNYYY) A X i COMMERCIAL GENERAL LIABILITY I 1,000,000 EACH OCCURRENCE ..,_ $ CLAIMS-MADE i XI OCCUR CLP 8665062 4/1/2022 411/2023 pDAMAGE TO el $ 300,000 MEDEXP,An A�Y,one person) $ 5,000 t __ PERSONAL¢ADYINJURY $ 1,000,000 OEN'L AGGREGATE LIMIT AP i S PER: GENERAL AGGREGATE $_ 2,000,000 POLICY 1 jECT LOC i P_RoD rs COMPKWAGO $ 2,000,000 OTHER.General Aggregate I ' A $ AUTOMOBILE LIABILITYOMBSINGLE LIMIT I-5 1,000,000 X i ANY AUTO BAP 8669261 7/1/2021 7/1/2022 BODILY IN RY(Perperson> $, OWNED SCHEDULED . AUTOS ONLY AUTOS SSWN p BODILY IN,14RY(Per accident) $ ..__.-AUTOS ONLY AUTOS O LY P ER t AGE $ B X 1 UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 —`EXCESS LIAB CLAIMS-MADE CXS 8669257 4/1/2022 4/1/2023 1,000,000 I AGGREGATE $i DED X RETENTIONS 0 _ _ $ B 1WORKERS COMPENSATION X PER OTH- ANDEMPLOYERS'LIABILITY Y!N I_- STATUTE ER WC 8665063 4/1/2022 4/1/2023 500,000 ;ANY OFFICER/MIMOREXCLUDED??ECVTIVE N i N!A EL EACH ACCIDENT $ _ E ggEE '](Mandatory in NW) 1 E.L.DISEASE-EA EMPLOYEE,1 „__.___._...._500,000 111 yes,describe under !4ESCRIPTIONOF OPERATIONS below i E.r.,01031y AT. 1(aiy , .p•IT 500,000 I I DESCRIPTION OF OPERATIONS!LOCATIONS!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 For Verification of Insurance Purposes OnlyTHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN p ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE • (?(,_7---7/4-4,— ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Teddy Bear Pools, Inc. ,scii-ry r 41 East Street • Chicopee, MA 01020 a ,1 e: , • • (413) 594-2666 • (800) 554-BEAR y>an FAX (413) 598-8823 Home Im rovemeni Cont. MA #11889/CT #520951 Pfkilliga-11:71:" ilk till '� T�EDDYBE�S.CiSI�A 9 TEDDY BEAR POOLS g SPAS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Nome Improvement Contractor RegiEtration Type: Corporation Registration: 111889 TEDDY BEAR POOLS, INC. Expiration: 02/07/2023 41 EAST ST CHICOPEE, MA 01020 n:•,P" r ^{4vr.p { •y ti i �r`i? ttip' '.� '��,y ^ya, 'o ?�'�,F,:• '' V;•y f. ,ti 5. .'�1 '''a w'. , 0:. ,C�f�!' �` .. le fir. °+ •§..^maw`,,: -,_r'-;:'',. r.' 5 V� 3 "i .V e '•.`�.Y,j.. 4 to Y?:$`;, t ...: .,_...___ ...._...._�._�.. $rb 1. r 1 S't ATF OF CONNECTICUT 4- DEPARTMENT Ok CONSUMER PROTECTION ,r` ' Y P Be it known that 3"$`,. TEDDY BEAR POOLS INC L ;, 41 EAST S'T r . CIIICOPEE MA 01020-2605 has satisfied the qualifications required bylaw and is hereby registered as aSi HOME IMPROVEMENT CONTRACTOR Registration # HIC.0520951 � y Pam, . . Effective: 12/01/2021 d fd, Expiration: 03/31/2023?,.7.-,', itlez i { f Michelle Seagull,Commissioner I Y Y{/ k�S i i �t.Yl,�.j « y r! "=S ',,, k s '' 1•ro'. x 7 W -_,0, , a 24,16"• =:. § ;a Ste'#.-1•: a. :.�" I- 4,,. ,.0 t r H `. { e: lec, ! ,,+�`3.-•r W ..`a:r, -.. `d , R:; ,, :.4 4 y:6: I. Z fire q' .t4'.*•''L::J '�}.. :i i i®,+ s y4J'�, S i �e��$,'Y c lei is a• . ,4*.'ti - ,. ^te• •, .t;,, � . c�, x•i [^^� Yt :wl,,`i,^:�yh�jh�i��'�,+; �'��.�� i¢.'��.f';&j ?�Kv}J'F"�t?'�'�z�'.�i Y t`�.STl=%'�"+t�..;r'i}. �.,�["y�Pl�, � .�} 1`�4 .•r r�R•. �.1'Yi '3y}PJ'• .,;?�: .'� ,�4�`• �i.-A. -�•�:,;. ',�`v�'•••.��j. J���` !•'^ A1h �.; ,r 1 v J •,..f r ti9 /y .', .r• w t if . V `.yr.+7.. ,,/ \t^. y�- �,\�' • 'Rh t .. :f�\j, . � •� Y` 1�•.•�l. r� � •�'y� v''1,�.1• y �1. '..1 Yv , '� 'S -�R, l'�•1�. ,,'d '� ■ (-----..- le- ---) • • • t Plot Plan ,, ,t, *411N Of jo TEDDY BEAR POOLS C SPAS 1 • ro.,4,0 The plot plan below is approximate measurements for the pool placement at the home of: Customer Info: l' 6ka j0S)3() In the City/Town of: \)Dsri/nel111 24611) Above ground pool set backs are: of House Side Rear Septic Leach Field i ' , 110011,1111 i ii ' ‘iiiiiiiiir ' a ' 1 111 1111111111 MIMI '-'t i gill ' i 11111111111 111. . , an ti SIIIIIIN 11MIIIIIIMNINNINNII 11 '.... '111111111111M1111 ' ' ' Ur IN 111 111 1111 Ilan INN , , sail insainan ennianurnial maimine 1 .. i ' — 11111111111111111111111111011 11111111111111111 , 111,111111111 ---- grilliAs' , gallImINLINININININI111.0411111111111%11111111111111111111 . ,pi FM IIINNI 1 ip 1 i 1 = iiimillaiini_ ',,,•", ”, „,„„____ %, ,,,,, , ,,,,L, ,,, , , 1111111111111 ; j , 4 11 1631, ._ , _.1 - , Envies , e ' Iii r• ___a , ' , , , , (-1 .i 11118 1 NO 1111.81 1111 1111111111111 IN 'Li imam al...•-• immilill —I— EN a6 ii ,..}... , 11111M114111.111 finallialli IR ' till i 411P :, 11111111nnalingialatM1110111111111111111 iiiiill 'k 1111111111111111111 i I 1 , an MIN _ 1111111111 ' ' 1 ' 1 1 , gimiii 1 -is Mai 111111111111 IN 11111111111 , , , num ,_,i MINI NNINININI NINSIWEirif 11111111111111 , 4,,,:. : 4_44_111111 ,,,,4,44_4 1 v a I '' inns a 1111111111111111111111111111111111111 111 ell M11 i mu 11111111011111111111111111111111111111MININ II 11 ..44 4 all '""- .4- Ifni 11111 $1111111111111111 IN in =1111111.11111 111111111 MN Rol MN Draw out you backyard including the back of your home and lot lines. Show measurements from lot lines, both sides and rear as well as from the back of the house. (See example on back of page). This plan was completed by: Date: 41 East Street • Chicopee, MA 01020 • (413) 594-2666 • (800) 554-BEAR • www.teddybearpools.com