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From :.5087541885 To: 14135871272 Page: 2/2 Date: 6/28/2010 10:15:53 AM
A DATE GIENDDNYVY
CORLL// CERTIFICATE OF LIABILITY INSURANCE DU 1 06(24`10
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF FORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Shea Ir Poor Insurance Inc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
292 Park Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Worcester MA 01609
Phone: 508 - 754 -3238 Fax: 508- 831 -9209 INSURERS AFFORDING COVERAGE NAIC #
INSURED INSURERA Max Speciality c/o Quaker
INSURER Er
Duckznan Pool' s LLC INSURER C:
50 Breakneck Rd INSURER D
Sturbridge MA 01566
INSURER a
COVERAGES
THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOT WITHSTANDING
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
POUCHES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IN= RoDI. POUCY EFFECTIVE POLICY EXPIRATION
ITR NERD TYPE OF INSURANCE POUCY NUMBER DATE (MMoDlYYYY) DATE (MEAAO/YYYYj UNITE
GENERAL MERIT( EACH OCCURRENCE $ 1,000, 000
A X COMMERCW L u HEN
GENERALM&UTY MAZ013100003273 04/01/10 04/01/11 PR EM�S (Ea occurence) $ 50,000
CLAIMS ASIDE I OCCUR MED EXP (Any one person) $ 5 , 000
PERSONAL SACV INJURY $ 1, 000 , 000
GENERAL AGGREGATE s 2,000,000
GEM_ AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000
Z POLICY PRO- IOC
AtITOMOMLE L ABILrTY COMBINED SINGLE LIMIT
ANY AUTO (Ea accident)
ALL OWNED AUTOS
BODILY INJURY $
SCHEDULED AUTOS (Per person)
HIRED AUTOS
BODILY INJURY $
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE UAIWTY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER TWIN EA ACC $
AUTO ONLY: AGG $
EXCESS! UE18RELLA LA MM/ EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
DEDUCTIBLE
RETENTION $ $
WORKERE COMPENSATION WC STATU- I I OTH-
AND EMPLOYERS' UAMUTY TORY LIMITS ER
YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE TO BE ISSUED BY CO11MY E.L. EACH ACCIDENT $
OFFICER/ EMBER EXCLUDED?
Mandatory In NH) CERTIFICATE TO FOLLOW E.L. DISEASE -EA EMPLOYEE s
T yes. describe under
SPECIAL PROVISIONS below E.L. DISEASE - POUCY UMIT $
OTHER
DESCRIPTION OF OPERATIONS V ACATIONS t VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT! SPECIAL PROVISIONS
swimming pools- installation, servicing or repair - above ground
Job: Nancy Mihevc, 51 Day Ave, Northampton, MA 01060
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER MIMED TO THE LEFT, our FAILURE TO DO 80 SHALL
City of Northampton REPOSE NO OBLIGATOR OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
fax #413 -587 -1272
210 Main Street
REPRESENTATIVES.
Northampton Mt 01060 � �V' lgdr iets .•�'�
ACORD 25 (2009/01) ®1988 -2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
RightFax N3 -1 6/29/2010 6:19:45 AM PAGE 2/002 Fax Server
•
•
ACORD. CERTIFICATE OF INSURANCE DATE(MIaDD1YY) 06 -29-10
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND COWERS NO RIGHTS UPON THE CERTIFICATE
SHEA & POOR INSURANCE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
292 PARK AVE ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW.
COMPANIES AFFORDING COVERAGE
WORCESTER, MA 01609
COMPANY
76R5K A TRAVELERS INDEMNITY COMPANY
INSURED COMPANY
a
DUCKMAN'S POOLS LLC
COMPANY
50 BREAKNECK ROAD C
STURBRIDGE, MA 01566 COMPANY
D
COVERAGES
THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD NOCATED, NOTWITHSTANDING ANY
REQUIREMENT, TERN OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT PATH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED
BY
TIE POLICES DESCRIED HEREIN IS SUBJECT TO ALL THE TERNS, EXCLUSIDNB AND CONDITIONS OF SUCH POLICES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLARIS.
CO POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE POLICY NUMBER DATE (MM1DDDYY) DATE (NMM1DDWYI LIMITS
GENERAL LIABILITY GENERAL AGGREGATE $
COMMERCIAL GENERAL LIABILITY PRODUCTS- COMP/OP AGO. $
CLAIMS MADE OCCUR. PERSONAL 88 ADV. INJURY $
OWNER'S && CONTRACTOR'S PROT. EACH OCCURRENCE $
FIRE DAMAGE (Anyone fire) $
MEa E.XPENSE,fAnyone persorl% $
AUTOMOBILE LIABILITY
ANY AUTO COMBINED SINGLE UMR $
ALL OWNED AUTOS BODILY INJURY (Per Person) $
SCHEDULE AUTOS BODILY INJURY (Per Accident) $
HIRED AUTOS PROPERTY DAMAGE $
NON -OWNED AUTOS
GARAGE LIABILITY
ANY AUTOS AUTO ONLY - EA ACCIDENT $
OTHER THAN AUTO ONLY:
EACH ACC(OEUr .R
AGREGATE $
EXCESS LIABILITY
UMBRELLA FORM EACH OCCURRENCE $
OTHER THAN UMBRELLA FORM AGGREGATE $
WORKER'S COMPENSATION AND
A EMPOLYEIt S LIABILITY UB- 0477N050 -10 05 - - nn4t 1 gT,AU tT£1RY WAITS X
THE PROPRIETOR! EACH ACCIDENT $ 100,000
PARTNERS/EXECUTIVE INCL DISEASE - POLICY LIMIT $ 500,000
OFFICERS ARE: X EXCL DISEASE - EACH EMPLOYEE $ 100,000
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES/RESTRICTIONS/SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
JOB: NANCY MDIEVC, 51 DAY AVE, NORTHAMPTON MA
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION
CITY OF NORTHAMPTON DATE THEREOF, THE ISSUING COMPANY WLL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE
TO THE CERTIFICATE HOLDER NAMED TO TIE LEFT, BUT FAILURE TO MAL SUCH NOTICE
210 MAIN ST SHALL IMPOSE NO OBLIGATION OR LIANUTY OF ANY KIND UPON THE COMPANY. ITS AGENTS
OR REPRESENTATIVES.
NORTHAMPTON, MA 01060 AUTHORIZED REPRESENTATIVE
ACORD 25-5 (3/93) Charles J Clark
•
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 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
home owner."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, to act as their own construction 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 backfill).,
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
iermits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made - 7 1 Al understand the above.
(Home ow der /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to
Date (O ~02 ^ / D
Address of work
location ,s i) / % Au ( lo U
o t If A ib o , (vtA '°/°G0
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor: /rAli) Not Applicable X
3, acg in ft--i\i5'poC)LS 1j � OV�p
Company Name I-I"'Q ‘o ., Registration Number
w C73 s re -57 ld r;
Address (
lY _V& 4 i $ Expiration Date
W U GsT IL L l$4A 0 / Co0 elephone ` 3i}?" d
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. N
Signed Affidavit Attached Yes ❑ No ❑ p) ( IUC.> Ff} t) 13 )( cc) u7 fa (-
11. - Home Owner Exemption
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 p 6 7' • ` (��ir
� t, U/
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors E
Accessory Bldg. El Demolition ❑ New Signs [0] Decks [Q Siding [D] Other NM
Brief Description of Proposed
Work: t NSTA Li Plrion() Ofd Ii-Y!'2& 5 (Ai /4tM Pc) oL /Cog 32.
Alteration of existing bedroom Yes X No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes )( No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
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. 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
I, A) A I✓ rY (. AA t + L $ Ol2.1 } j /J L , 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.
N A uc=-Y A. 14 c-_ ki 0 4-414 k t 14- u
Print Name
zgpo
Signature of Ow er /Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front /10
Side L: R: L: Q R: �S
Rear ��V
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW ® YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO • DON'T KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q , Date Issued:
C. Do any signs exist on the property? YES (3 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO lip
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 ® NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
_- - — • City of Northampton Status of Permit:
^; S \\ Building Department Curb Cut/Driveway Permit
r
212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
��N 2 9 2010 Northampton, MA 01060 Two Sets of Structural Plans
phonei413- 87 -1240 Fax 413 - 587 -1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
51 h /4 `/ u c to u t' Map Lot Unit
/U n VL7H A vv. P f� 0/06
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
P A IJ[,Y T. u1 i it v c,1 h Eg0lL A- H L. / 3 /1/ /0001114u ®7vu
Name (Print) Current Mailing Address:
—sts �1
Telephone
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
completed by permit applicant
1. Building 3 p (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 q,
6. Total = (1 + 2 + 3 + 4 + 5) Check Number 3 p 030 —
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2010 -1205
APPLICANT /CONTACT PERSON MIHEVC NANCY T & DEBORAH KEHNE
ADDRESS/PHONE 51 DAY AVE NORTHAMPTON (413) 585 -9011 0
PROPERTY LOCATION 51 DAY AVE
MAP 25A PARCEL 131 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out �q
Fee Paid J 0 4,1 3
Typeof Construction: INSTALL 16 X 32 ABOVE GROUND 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
IN.F PRESENTED:
V 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
/pW 7/
Signature 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.
51 DAY AVE BP- 2010 -1205
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25A - 131 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2010 -1205
Project # JS- 2010 - 001749
Est. Cost: $8300.00
Fee: $30.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 39683.16 Owner: MIHEVC NANCY T & DEBORAH KEHNE
7ontn¢„T. JRS(100)/ Applicant: MIHEVC T & DEBORAH KEHNE
AT: ' 51 DAY AVE
Applicant Address: Phone: Insurance:
51 DAY AVE (413) 585 -9011 0
NORTHAMPTONMAO1060 ISSUED ON:7/1/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: INSTALL 16 X 32 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: ' ( py l House # Foundation:
I/ � Driveway Final:
Final: Final: a , 3 4 ; f
�'cs� Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: Ok 941 CAW
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGU � '44AZ* •, /4 i/LOti�1r�
Certificate of Occupanc � ienature:
FeeTvpe: Date Paid: Amount:
Building 7/1/2010 0:00:00 $30.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo