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OZOlO VW `eadooiu0 1.960Z9# 'luo0 luawanoldwl ewoH 10 e si� ' •ONI `SlOOd IA' ,...4s ,...4s Ise3 11 6881 l I-# 1u00 luawanoadwl ewoH VW EIV38 A0a31 Northampton, MA,Proper,jy Detail Page 2 of 2 Interior /Exterior: Same Condition/Desirability /Utility: VG Vacant /Dwell /Oby Status: Dwelling Additional Features: Brick Trim: 0 X 0 Stone Trim: 0 X 0 Remodeling Data: Year Remodeled: 2005 Kitchen Remodeled (Y/N): Yes Bath Remodeled (Y/N): Land Data Outbuilding Info Square Foot Type Type Feet Utilities Prime no Site 22,000 99,200 information Residual 14,261 4,990 Type Qty Year Size 1 Size2 Grd Cond RS1 1 2002 1 100 C A Acreage Type Type Acres Value Street /Road no no information information Sales Info Permit Info Date Type Price Validity Date Permit # Price Purpose 06/01/2005 Land + Bldg 370,000 0 07/01/1986 Land + Bldg 170,000 0 no information http: / /www.northamptonassessor.us /noho /propertydetail.php ?map_no =37 - 078 - 001 &pagec... 3/14/2011 Northampton, MA Property Detail Page 1 of 2 City of Northampton., MA: Residential Property Record ( New Search Property Type Classification Code Reference Card 1 of 1 Parcel - Location - Zoning - Assessment Map -Block -Lot: 37 - 078 -001 Zoning: LA307 Assessment: Location: 49 PLATINUM CIR Neigborhood: 18 Land: #Living Units: 1 Deed Book: 8284 Building: Class: R -101 Deed Page: 122 Total: Dwelling Information Building Sketch Style: Col /Gam Year Built: 1986 Story Height: 2 Attic: None Basement: Full Total Rooms: 8 1 14 1 Wood Deck Bedrooms: 4 14 (.14;) Full Baths: 2 28 42 Half Baths: 1 Exterior Walls: Alum/Vinyl FG Unfinished Area: 0 24 452 24 26 2Fr1B Ground Floor Area: 1148 Total Living Area: 2296 28 14 12 28 Finished Basement Living 0 X 0 Area: Basement Recreation Area: 0 X 120 Woodburning Fireplace 1 / 1 Stacks /Openings: Metal Fireplace 0 / 0 Stacks /Openings: Addition Information: Heat/Central A/C: Central Air Heating System: Hot Water Lower 1st Story 2nd Story 3rd S Fuel Type: Gas Basement One Story Frame One Story Frame Quality Grade: B+ Frame Garage Physical Condition: Good - Wood Deck http: / /www.northamptonassessor.us/ noho /propertydetail.php ?map_no =37 - 078 - 001 &pagec... 3/14/2011 03/01/2011 13:43 4135988823 TEDDY BEAR POOLS PAGE 02 �, � � DATE (MMIDDIYYYr -- TM. CERTIFICATE OF LIABILITY INSURANCE 04t01/2mo pRODUCER Paanc: (413) 7B1.241O Fax, 413 - 771 - JG39 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION INSURANCE CENTER OF NEW ENGLAND ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P O BOX 1175 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR VILEST SPRINGFIELD MA 01090.1175 ALTER TI-IF COVERAGE AFFORDED BY THE IDOL CIES BELOW. • INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Arbella Indemnity Ins Co Teddy Bear Pools, Inc & TGH Leasing, Inc- INSURER B; _ 41 East St INSURER C: Chicopee MA 01020 INSURER D; M W..__.,.,.,r — COVERAGES • THE POLICIES Or INSURANCE_ LISTED BELOW HAVE BEEN ISSUED TO INS INSURED NAMEO'AROVF FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING MY REQUIREMENT, TERM CR CONDITION OF ANY CONTMCT OR OTHER DOCUMENT wm RESPECT TO WH C41 THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCO AFFORDED FY TFIE•POLICIP,S DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF OUCH POLICIES. AGGREGATE LIMITS SHOWN MAY NAVE BEEN MOUCED BY PAID CLAIMS. -•– I NOR ADO1 TYPE OF INSURANCE , POLICY NUMDER POUCY P3P(!OTIVi{ POLICY EXPIRATION _ - - - -- LIMIT$ L1•11 MIR D{ P 0 ,013 PA k, to 0 GENERAL LIABILITY STT8500042$72 04/01/10 04/01/11 EAr,H DccuRRENcE _. a_ 1,000,000 unt oto ro irry 1 X COMMI;RCNLGENi RALLIABILITY PREMIRI" -D nnrsim,nrn _ S 100,000 CLAIMSMAOE� OCCUR MED,F (Any one person) _- $ -� 5,000 • 1 A _ _.— PERSONAL S. ADV INJURY $ 1,000,000 GENERAL AGGREGATE 0 2,000,000 • OF,N'I, AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP A(]C1, R Z000,000 POLICY .1 LOC AUTOMOBILE LIABILITY 31270400003 07/01/10 07/01/11 COMBINED SINGLE LIMIT ANY AUTO (En accident) $ 1,000,000 ALL OWNED AIJTOA BODILY INJURY • T - -�� X SCHEDUI.bnAUTOS (PCrpohttn) $ - - -- A X HIRE OAUTOS BODILY INJURY X NON -OWN1/ AUTOS (Par Weldon!) $ PROPERTY DAMAGE g Per nccldgnl GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ - -. r ANY AUTO • OTFIER THAN E)1 ACC .$ AUTO ONLY AGC $ - • I 0XCES0 UMBRELLA LIABILITY EACH OCCURRENCE $ • , . –_ - - I OCCUR � 1 CLAIMS MADE ACORE<IATF „•- •_ -_– 4 __• $ —1 DEDUCTIBLE RL $ q we BTATU. I WORKERS GOMPDNSATION AN n 9104140409 04101/10 04/01/11 TSIRYLIM OntElt EMPLOYERS' LIADILnY ' ---- "' - - - - ' A ANY PROafICTORIPARRNERJCxYCUTN. k•I., EAC1iACCIDENT 500,000 CiFFICEPIMPIent ri EXCLUDED7 E.L. 0I$EA.sE.EA $ 500,000 II 'r GI tlLhIle!vI3ION D pe Ia E. L. DISEASE - POLICY LIMIT • ., $ 500,000 • t•cAL naelslDNW . OTHER: DESCRIPTION OF OPERATIONS /LOCATIONS/VEHICLES/EXCLUSIONS ADDED EY ENDORSEMENT / SPECIAL PROVISIONS CERTIFICATE HOLDER . CANCELLATION SHOULD ANY OF THE ADOvl/ DESCRIBED rouc1Es DE CANCELLED EEI'oRETHE_ EXPIRATION DATE THEREOF, THE, ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN NOTICE TO TId2 CERTIFICATE HOLDER NAMED TO THF, LEFT, BUT FAILURE TO WHOM IT MAY CONCERN TO D0 SO SHALL IMPOSE: NO ORL IGAtION OR LIABILITY OF ANY MINA UPON THE INSURER ITS AGENTS OR PEP RE$ENTATIVES. • ALT} {ORI7.ED REPRESENTATIVE • Attention: • I fU ACORD 25 (2001108) Ce1tI0catc t 49028 • GJ ACQRD CORPORATION 1988 • 780 CMR STATE BOARD OF BUILDING REGULATIONS AND STANDARDS . THE MASSACHUSETTS STATE BUILDING CODE sECTION 4 =W O___ .coo x a tANCWArrpOrr W a.L. a 152.1 s49(s» :1 • Workers Compensation Insurance affidavit m completed and submitted with this application. Failure to provide this affidavit will result in the denial of the ce of the building permit. Signed Affidavit Attached Yes....... No 0 stark* 5 x`DI:8C :041os DiuPitoPOS1 WOBa (c>ierx asagpticabtel 1 New Construction o ESdsting Building 0 Repabis) o 1 Alteration(s) o f Addition 0 Accessory Bldg. o Demolition 0 Other 0 Specify: Brief Description of Proposed Work • /6A-3/ /oil/ou/7 3ECT1ON6 GOl 01i l .. ` - :•ASS & ...&YaS °.3'Y)'$#,L °'A'Lfi :. Item Estimated Cost (Dollars) to be ` 'Else ©D3� L« completed by permit applicant• ; 1. Budding 2. Electrical _ p1 f _ 3. Plumbing 4. Mechanical (iVAC) k [ Yee A `� 'k•Y_L� 5. Fire Protection ft 2?' Y a:.: k ..yS 6. Total- (1 +2 +3 +4 +5) be ;:' 'alECTIO**aViiiiNEltALITUORfibiriblOiTOTB*.:; 2 : : ;77 e 1. . as Owner of the subject property hereby uthortze to act on my be rs to work authorized by this building permit appbcatlo . -i lQ /2 / • S :.. w. of Owner Date SECTION 7b OWIVER/ADT1101OZZD AGElIT D11 cLARATION.'.1 1. . 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. Signed under the pains and penalties of perjury. ro Print /�- Q 12 /0 t ure of owner /ant Date 672 780 CMR - Sixth Edition 2/7/97 (Effective 2/28/97) • 780 CMR:' STATE BOARD OF BUILDING REGULATIONS AND STANDARDS APPENDIX B 2Z, The Commonwealth of Massachusetts State Board of Building Regulations and • !_. 0 Standards Massachusetts State Building Code 7130 CMR FOR MUNICIPALITY USE APPLICATION TO CONSTRUCT. REPAIR. RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING ':*-4 OMMIATsii:OPIF V504 !:.'.';' TV.: ' - ..::" F7Citiiii4 I iitioi: t w*-Twt; . '--:,....., ---..- --::::- ,,,.....: ariMME'i',2..'..K.:Agswewtr, grAeZte;4010.0.4e*iithiiikaani.e.f.Buiti!..imi;i::::- . :•'...1".: ..:-. '''': ;P■t*rikTOP74:iii:::'--: igizoTIOICIZOKTEActroptertort;.-...iill 1.1 Property Adelniir in i 1.2 Assessors Map & Parcel Number 4. //i/ eh( 64._ Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use • Lot Area Is° Frontage (ft) 1.6 Building Setbacks (ft) Front Yard Side Yards Rear Yard Reqtdred Provided Required Provided Required Provided / / 1.7 Water Supply (M.G.L. c. 40. $ 54) 1.5 Flood Zone btformation: 1.8 Sewage Disposal System: Public 0 Private o Zone: Outside Flood Zone a Municipal 0 On site disposal system o . ... , .. . . . .. . SEPTION 2.1 Owner of Record: Name (Prin() Address for Service Signature Telephone 2.2 .h ;r7 , le/Li I . Name (Print) Address for Service: Signature Telephone sacimita4 onsTImort arni1mw,f1 3.1 Licensed Construction Supervisor: Na Applicable a licensed Construction Supervisor License Number Address Expiration Date Signature Telephone 3.2 Regist . : ome • . proem ntracto I Not Applicable a ,, .. -- , ., i t ,,,,, 5 - A : ' . . ) 1 / 5/ 1 affairj a / o 242 Re:+ trail° Nu • r S' i i / Expirati• D te Add arlislyil 3 Si: r ature Telephone 2/7/97 (Effective 2/28/97) 780 CMR - Sixth Edition 671 ,....,, I3/@1/211 13:43 4135988823 TEDDY BEAR POOLS PAGE 01 5SLo '." ( ( 3 C) . • ,., . .,., Teddy Bear Poois, inc. ,, Known By Our Reputation 41 East Street , ( 41:-:1 " i413) 594-2666 . 1-800-554-BEAR ;,... 4 , , , '1' M chicapee, MA 0100-3562 I" , . FAX 1413) 598-8823 Home traprovetnent Cant. MA #11889/CT 0520951 ' , 1, r, wvvor.teddybearpooiscomn (11?4,, , ,v i ir.'1,:,,.,',:. : '.., , '',': ,' :. 1 : . . '1`' ' • . .,'.:' ., ' , ':,.''''''',',.'',.',., , . :,- ....,.' ,;:,. :,.,r ,. 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TEDDY BEAR POOLS 8: SPAS IN , . , , , ,... , .:... , ,,! . .. , . , ,,,.„..... , Iy....-.....,. , ...- .,„,. THEODORE HEBERT , \"z : ., ; •;.,,.i...::::,•:.;. , ,,',.,., , ;.,..,..; ' -' - - 41 EAST ST „.,„% •,,,,,,,,,,,,,,,, ,-::,. 4 . ” .. ■.;:- ' i ' ' i ..( .. ' r .. , ', .., . ■■■ CHICOPEE, MA 01020 `•:,,;: '....,:: :..•' ' ____ .....„, , .y . .. ) ,,,. ' .. ....•...,.... -, ::::c', , , - ;:..;,: . ::::-'...', Ut]date Address 0E1(1 return c.a rd. 11/taric reason fur change. '''''::""!';+".•■ ';' / . • -••••i , , ',' i" 1:11 Address [ Renewal [1 Employment LIll Lost d kro.nni e.5 50114-04/01-Ci101216 l' v...;,; f ; , ■ 'g. . i "e: - ii,...?;,,., • ‘1:7r.17:777j, ,,„ ' ., , itl.:4 1” ,,- ,.. ,i , •,, . 1. qv., - 1 ,;;.• ' r; pg AN,v; ,. oftz,, l'r fri J i qiiri 1 , ' V, ‘ ',, .1.',0t.i.:111 ' ' , i'ii,.;,.. 0, .1e Vit:. 4 thY077: ...,1 9, gOir 44,4, 1 ,,,Fh0 ' ,,'1,1 4 ,%., ''X' t'4 ,ff$ill ,, • ',Irv/A dr .• 4 ifilVA'r tr•V. iP, 47 ;'al,;(; 1;(..picgi 1 ,,, , . 1 p4. 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E:kiiiia.... - . ;...• • • • ... 1 . ... ::..... . . .1 .c.,.., .. • .,.. ...:.,.:H ..,./...,-7 ,,..:0;.!): .,-;,, . ..., ..- .. ' • • ' ..... ,. ' . . I '• . • • • '. C7innlig/iiorrer ...- - .:-.. • . :;... ,11. ,. 1 ,' 4?,,,q, - • ; " • • „,,.4.,.,,,,,;,:, ,,,,,.,..,.....,",""7,:, ,.: ";.,;:.; _,;_,—, ',,_:.. ; • ,,,,.'.,", i .", ,.,;........ ,,..,, .7 — :,;,:,., ' , r . ' 1 1 4140 1'1 )1AIM .: , l 'i. .;I : •••.:-, \Ai • `1..i.ii.'evAVi'i 4.'',')' •{ 1.. , lgiri,: . .. 4 •:' 14 1 7 (.' , '.'.A1' , Ig4 ,,,'!,', . ,+1,A . , ■"14)‘ , k li , +Aii,./.•%1`17,4%•q444, • 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 fami47 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 hone owner exemption, - to act as their own constructi n`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 backed!), 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 inspections 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 ins ections. Failure of the individual trades to secure the permits and inspections as r uired can DELAY the project until such time as the proper permits and inspections are de �� / Lki.1_ 1 (. 4 _ �4111 understand the above. (Home owner /resident's si • re requesting exemption) I will call to schedule all requires building inspections necessary for the building permit issued tome. Date .3 i Y /!/ Address of work f (r' location Tr 1 (r-4.^ v -4^ C c 0 A- t.xiLr 2 Ai'. k 0 ( Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub - contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Lia iility Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retumed to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self - insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. .. _ • _ The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone -and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617- 727 -4900 ext 406 or 1- 877 - MASSAFE Fax # 617- 727 -7749 Revised 11 -22 -06 www.mass.govldia The Commonwealth of Massachusetts __ Department of Industrial Accident � _ _ • 1 = Office of Investigations Vi= 0. 600 Washington Street Boston, MA 02111 �� . www.mass.gov /dia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): � -&-tff Address: 1 e01 City /State /Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): / 'Ar b 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. ❑New construction listed on the attached sheet. 7. 0 Remodeling 2. ❑ I am a sole proprietor or partner- ship and have no employees These sub - contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' $ 9. 0 Building addition [No workers' comp. insurance comp. insurance. 10. r a required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their . 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other 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. Contractors 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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self-ins. Lic. #: Expiration Date: - 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 Section 25A of MGL c. 152 can lead to the imposition of criminal 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 fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investieations of the DL& for insurance coverage verification. I do hereby certify under the pains and penalties of perjuty that the information provided above is true and correct Signature: Date: Phone #: 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. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Su • is .. 4 I Not Applicable ❑ Name of License Holder • . �. ,O, I License Number Address Expiration Date Signature Telephone 9.;<Ret1 tere t:H`o> iffier Irngrtvetnerrti0a t r"gka N - gl : relV.. w M,MM. U:1 Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 452, § 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 ❑ 1.. H ome `n er .�: e o 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" certifi s and assumes re onsibil• for compliance with the State Building Code, City of orthampton Ordinances, State Z ' L nd S of Massachusetts General Laws Annotated. Ho meowner S ignature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks (El] Siding [0) Other pik Brief Description of Proposed i / Work: f li 5 I (ot D 1 ^ �''�d FE) ([ /(o X310 Alteration of existing bedroom Yes ) No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes )4 No Plans Attached Roll - Sheet sa:`C� F[e tt i s h 1 . .. i k ta.Eis I q'hO'i mq ce rn fe> ., nill r rlli q: a. Use of building : One Family X Two Family Other b. Number of rooms in each family unit: y Number of Bathrooms a c. Is there a garage attached? Nt s d. Proposed Square footage of new construction. Dimensions )C 36 (fed) 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 - TO BE. COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT , as Owner of the subject property hereby authorize 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. Signed under the pains and penalties of perjury. „oh AllIr Print Nam = / AA- 3 Pik Signature of ner /Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomp4ete Inforfmation Existing Proposed Required a Zoning i This column "• be filled in by Building D • , rtrnent i4A C, ` 4 Lot Size x _ _w _..,:.,m..«.1 . i Fronta_e , ` Setbacks Front , , Side L: E R: i L:751 R:' Rear i s 3 Building Height [ i Bldg. Square Footage . Open Space Footage % (Lot area minus bldg &paved s j ; 77 1 - parking) # of Parking Spaces Fill: F (volume & Location i A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW ft YES 0 7 IF YES, date issued:3 I IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book I 1 Page: 1 and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES Q 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 0 NO IF YES, describe size, type and location: i ; D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO p 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 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. a a � ity of Northampton �� RECEIVED = uilding Department V .a 212 Main Street Room 100 1 R N • hampton, MA 01060 phon- 13 .87-1240 Fax 413 - 587 -1272 m a = PPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 SITE INFORMATION This section to be completed by office 1.1 Property Address: 1 1 10 ' { r ' _fi Map Lot Unit t%t Zone erlay District k ! r Ce t M Eini St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 1 C,LgnJn/ �- J ycgt vW c �dL y `l9' P %a f 4 vn,► P/171?,1 c' Name (Pn tt �� / ^� /) Current Mailing Address: /3 I A / Telephone Signature J 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 completed by permit applicant 1. Building <S,Aa, a ee7 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 075 6. Total = (1 + 2 + 3 + 4 + 5) Check Number 110 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building; Commissioner /Inspector of Buildings Date • File # BP- 2011 -0724 APPLICANT /CONTACT PERSON CONNLY GLENN R & JACKLYN M ADDRESS/PHONE 49 PLATINUM CIRC FLORENCE (413) 587 -9848 Q PROPERTY LOCATION 49 PLATINUM CIR MAP 37 PARCEL 078 001 ZONE SR(100) //WSP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out �i 14,0 Fee Paid Typeof Construction: INSTALL 16 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 THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON I FO 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 3/2.7/ Sign re 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. 49 PLATINUM CIR BP- 2011 -0724 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 37 - 078 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Inground Pool BUILDING PERMIT Permit # BP- 2011 -0724 Project # JS-2011-001196 Est. Cost: $32000.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: TEDDY BEAR POOLS & SPA Lot Size(sq. ft.): 36241.92 Owner: CONNLY GLENN R & JACKLYN M Zoning: SR(100) //WSP Applicant: CONNLY GLENN R & JACKLYN M AT: 49 PLATINUM CIR Applicant Address: Phone: Insurance: 49 PLATINUM CIRC (413) 587 -9848 () FLORENCEMA01062 ISSUED ON:3/24/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 16 X 36 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 3/24/2011 0:00:00 $60.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner