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16A-027 Apr 11 13 08:28a POOLTECH 14135349869 p.l ACORQ C RTIFICATE ; OF -LIABILITY INSURANCE D ATE (MMJDDIYYYY) ot /ao /oiz 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 THE COVERAGE. AFFORDED DY THE'POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES.NOT CONSTITUTE A.CONTRACT.BETWEEN THE ISSUING-INSURER-in AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, • IMPORTANT: If the certif Bate holder is an ADDITIONAL: INSURED, he polley(les) must enciprsed, If SUBROGATION. IS WAIVED, subject to the terms and conditions of thepolicy;•certain policies may require an endorsement. A statement on this certificate does >not :confer rights to the certificate holder In Ilea of such .endarsefhei'tt(s).. PRODUCER _ LONTACT ,. NAME: Martin J. Clayton Insurance Agency, Inc,, PHONE ” e ix Y 9 Y ( Arc No, EMI: 413.536.0804 we Noy 413.534.7874 1649 Northampton Street a -M ADDRESS: P. O. Box 989 INSURER(S) AFFORDING COVERAGE NAIL s Holyoke, MA 01041 - 0989 INSURER A: AIM MUTUAL INSURANCE COMPANY AIM NSURED Richard Dupuis INSURER B: • DBA: Pool Tech - INSURER C P.O. Box 705 INSURERG: Hol yoke, MA .01041 JNSURERE: • • COVERAGES -CERTIFICATE NUMBER: POOL TECH • REVISION:NUIMBER: THIS IS TO CERTIFY THAT THE POLICIES, OF INSURANCE LISTED BELOW HAVE .BEEN ISSUED TO THE INSURED •NAMEDABOVEE'E0R THE!P0p1GY .PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH'RESPEtT TO WHICH THIS CERTIFICATE MAY BE ISSUBp O,F , M,, } pARTAVIN� THE;; 1,plSLIRANCE AFFORDEL :B.Y,,T}(E P , I =S DgSCRIBED HEREIN IS S4pJF ; T TQ A1:L THE TERMS, EXCLUSIONS AND CONDITIONS CO S � Y I PotIDIES. LI( I'fryafie1Y IV3GG4'1 HAVE13LEI3 lJCtpAYPA11b CliA1NtS, . JSR Auu1,BUBK POLICY—Ere POLICY EXP -TR TYPE OF INSURANCE .. INSR WVD POUCY NUMBER LIM (MM!DDfYYYY) M /DD1YYYY) -ITS - GENERAL LIABILITY EACH OCCURRENCE . $ COMMERCIAL GENERAL LIABILITY UPNIAGk Nt PREMISES (Ea occurrence) S CLAIMS MADE Li OCCUR MED EXP (MyorSe'yeraon) S ' , PERSONAL &A INJURY . $ GENERAL AGGREGATE $ GEN'L AGGREGATE UMITAPPLIES PER: • PRODUCTS - COMPIOP AGG . $ — 1 POLICY I I J ECT n LOC S . , AUTOMOBILE UABILITY E d IfI4iL'N, S ANY AUTO BODILY INJURY (Per oilman) S ALL OWNED SCHEDULED BODILY INJURY (Per accident $ AUTOS AUTOS . HIRED AUTOS NON -OWNED • PROPtR1Y• ' $ AUTOS (Per accident) . $ UMBRELLA LIAB OCCUR EACH OCCURRENCE • $ EXCESS LIAR CLAIMS-MADE AGGREGATE . $ DEC j I RETENTION'S AND'EMPLO EMPLOYERS LIABIU1Y - Y J"N VWC6002547 - 0810412613 X [70RYL(HI S 7 i ) ER WORKERS COMPENSATN ANY PROPRIETORIPARTNERJEXECUTIV E.L. EACH ACCIDENT s 100,000 A OFFICER/MEMBER EXCLUDED? 1 N / A _ (Mandatory in NN) E.L. DISEASE - ;EA EMPLOYEES 100,000 If y es, describe under - DESCRIPTION OF OPERATIONS below , EL DISEASE - POLICYLIMlT -$ goo , 000 • DESCRIPTION OF OPERATIONSI LOCATIONS! VEHICLES •(ANach ACORD 101, Additional Reworks Sctjedule, Ifmorerspace:la required) • • CERTIFICATE HOLDER . CANCELLATION • SHOULD ANY OF THE ABOVE DESCRIBEc: PoLrrIES HECANCELLEfeBEFORE THE EXPIRATION DATE THEREOF, :NOTICEIMLL BE DEUVEREVIN ACCORDANCE WITH THE - POUCY PROVISIONS. POOL TECH THOREED= REPRESENTATIVE P O BOX 705 , HOL MA. 01041 ,�(� ©1988-2010 ACORD CORP7+� Ali rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered- marks of ACORD // 1:-J ico .,. Lee& 1 .. 39 . . ,./ , i Pt Mtit \ I \ d/ , 6p0,4073 p46,,,, \\\ ; 4.5 I i . . ,f. I at) 1 1 ki,k1q0 i, 1 0 r 1 6 MIME: A 1 , i t 1 K •i Lid ) 1 , f'- - - - - -- N ) 7//g) , 17 4" OCA fa dUe.:' /IC; 4PA _, ' • -L7r: , ; , ; , :i0 ‘ 47.:::0' . . Sr eyk !:) (2' 7i) v • 6ill City of Northampton 4:5 0 S( . t'"#^ Its �•� �_ Massachusetts c: k �; !€ DEPARTMENT OF BUILDING INSPECTIONS r zs 212 Main Street • Municipal Building Northampton, MA 01060 INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner 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 any 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 backfilf, 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 permits 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 1, /7 S 24/4 understand the above. (Home owner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date 11 -4) ' Address of work location j CAi --AC i)e W.D_ ee.af, !4/7 • 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 ipdividual, 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 deepied 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 your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability 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 returned 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). 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 1 Congress Street, Suite 100 Boston, MA 02114 -2017 Tel. # 617 -727 -4900 ext 406 or 1-877-MASSAFE Fax # 617 -727 -7749 www.mass.gov /dia Form Revised 7/2010 The Commonwealth of Massachusetts Department of Industrial Accidents t tom, �, �,:r „� , Office of Investigations i == 1 Congress Street, Suite 100 1l Boston, MA 02114 -2017 A14 1#18 www.mass.gov /dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information ` • ''Please Print Legibly • Business /Organization Name: Address: City /State /Zip: Phone #: Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. ❑ Retail or part- time).* 6. ❑ Restaurant/Bar /Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7. ❑ Office and /or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ['Entertainment their right of exemption per c. 152, § 1(4), and we have 10. ❑ Manufacturing no employees. [No workers' comp. insurance required] ** 11.0 Health are 4. ❑ We are a non - profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City /State /Zip: Policy # or Self -ins. Lic. # Expiration Date: 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 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: 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. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: ww w.mass.gov /dia 1 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: Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone 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. Signed Affidavit Attached Yes ❑ No ❑ 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. Defmition 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 e2 -".,.elf21.1 6..t ° 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 [D Siding [D] Other Brief Description of Proposed ' / , /C f r Work: �/'���?I?!� r� /.%� �7✓/ °`'4 f��J� f ". Alteration of existing bedroom Yes 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 1. 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 Ta - 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 in /WW1( , Q 24/4 , 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. 7r>,//7 S:, 24 Print Name D / ��✓ /� /� 72%f/ OA/ //k Signature of 0 - r /Agent Date Section 4. ZONING AU Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by /f Building Department Lot Size C/ / ei1 - 6! Frontage /o/ P' /a' Fe et Setbacks Front /l Side L: fi -3d1 R: ; 7 O / L : 3D' R:W Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved Ping) - - # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DON'T KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW ® YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ® , Date Issued: C. Do any signs exist on the property? YES ® 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 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 I F YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit RECEIVED 1 Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability 1 U 2013 Nort hampton, MA 01060 Two Sets of Structural Plans phone 413- 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans IRPr: OF BUILDING INSPECTIONS Other Specify NORTHAMPTON, MA 01060 APPLICATION 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: Map Lot Unit /' 6.164Z i71 RD, ,Lee s Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 1 )A1 R l A 27%%' 4 CX P.s Pi1'7' P,edS "(' Name (Print) Current Mailing Address: 0 /0. 7171a4".%/_,/ Tea‘eJv) SW c�. r (7,3 . Signature 2.2 Authorized Agent: / S ' L M/, c4 Name Print �; Current Mailing Address: ��� 1 7 . (7//1) S S " ..F Signature f Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building .$ 'h2 /Pi 1),,g Qd (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 s 6. Total = (1 + 2 + 3 + 4 + 5) / ‘94 t70 Check Number C54- # (5° -- This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date A . File # BP- 2013 -0932 APPLICANT /CONTACT PERSON BLAIR WAYNE J & MARTHA S O K ADDRESS/PHONE 16 CHESTERFIELD RD LEEDS (413) 582 -0328 0 PROPERTY LOCATION 16 CHESTERFIELD RD MAP 16A PARCEL 027 001 ZONE URA(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 51 / #06 Fee Paid Typeof Construction: REPLACE 24' WITH 21' 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 F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF 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 .°____ f tti 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. 16 CHESTERFIELD RD BP- 2013 -0932 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 16A - 027 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- 2013 -0932 Project # JS- 2013- 001579 Est. Cost: $1800.00 Fee: $30.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 84680.64 Owner: BLAIR WAYNE J & MARTHA S Zoning: URA(100)/ Applicant: BLAIR WAYNE J & MARTHA S AT: 16 CHESTERFIELD RD Applicant Address: Phone: Insurance: 16 CHESTERFIELD RD (413) 582 -0328 0 LEEDSMA01053 ISSUED ON:4/11/2013 0:00:00 TO PERFORM THE FOLLOWING WORK: REPLACE 24' WITH 21' 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. Certificate of Occupancy Signature: FeeTvpe: Date Paid: Amount: Building 4/11/2013 0:00:00 $30.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner