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17A-153 (4) i w �� Cl TEDDBEA-01 MPROULX CERTIFICATE OF LIABILITY INSURANCE 7313112016(MM1DD/YYYY) 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 NAME: Insurance Center of New England,Inc PHONE 1070 Suffield Street / e .(800)243-8134 n/c Ne; 413)731-9539 Agawam,MA 01001 —AIL. ADDRESS: INSURERS AFFORDING COVERAGE NAIC N INSURER A:Acadia Insurance Company INSURED INSURER B:ALL AMERICA 20222 Teddy Bear Pools Inc. INSURERC: 41 East St INSURER D: 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. ILTR TYPE OF INSURANCE INSD POLICY NUMBER MM/D E -POLICY P LIMITS A X COMMERCIAL GENERALLIA131UTY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE T OCCUR CPA0382188-13 04101/2015 04/01/2016 PREMISES Ea occurrence $ 250,00 MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,0 POLICY D PRO- LOC PRODUCTS-COMPIOPAGG $ 2,000,00 OTHERS Broad Form Endt $ AUTOMOBILE LIABILITY 0NGLIMIT EaaBdt $ 1,000,00 B ANY AUTO BAP 9655061 07/0112014 07101/2015 -BODILY INJURY(Per person) $ ALL AUTOS ED X SCHEDULED AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OVMIED AUTOS $ Per acddent $ UMBRELLA LU1B OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION _ AND EMPLOYERS'LIABILITY X STATUTE ERH A ANY PROPRIETORIPARTNER/EYECUTIVE YIN WPA0382194-13 04/01/2015 04/01/2016 E.L.EACH ACCIDENT $ 500,00 OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 50000 If yes,describe under , DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMB $ 500,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) To show evidence of Insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Verification of Insurance Purposes Only THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Teddy Bear pools, Inc. � known By Our Reputation 41 East Street �' (413)594-2666 - 1-800-554-SEAR Chicopee, AAA 01020-3562 FAX (413)595-8523 Home Improvement Cont.MA#11889/CT#520951 AD BIVww.teddybearpools.com MENe a Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massach �tts 02116 Dome Improvement C t�rctor Registration Registration: 411889 Type: Private Corporation Expiration: 2/8/2017 Trill 260956 TEDDY BEAR POOLS & SPAS INC' W THEODORE HEBERT 41 EAST ST CHICOPEE, MA 01020 date Address and return card.Mark reason for change. 20M-05f1t SCA 1 t3 E] Address n Renewal R Employment F� Lost Card �ii Will .- ... : ., -...fir—.--4--4-5-^• :' Tt 'I E OF C 10Tl�t C 'I 7I'. + TM EN.I' �' Ol'�SIJIVIER PI�OTE TI�1�T Be OW, —that 41 E.A.S I' ST C"1C0PEE, NIA 02020 , b 1. is certified by the Depa-ttn.ent of Consul nek Ptotectioi as,4 registered' ONE: RONE CTOR . ., 12 eg s,tatj 0n #MC 0520951 TEDDY BEAR POOLS 11-40 Effell '12/01/2614 Ex na-fi®n 11/30/2015 William 1Gf Rubenstein,Commissioner` The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations r. 600 Washington Street ,;: �- Boston, MA 02.1.11 x wwwanass.gov/dia Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Narne (Business/organization/individual):Teddy Bear Pools & Spas Address:41 East Street City/State/Zip:-Chicopee, MA 01020 Phone #:413-594-2666 Are you an employer?Check the appropriate box: Type of project(required): 1 100 4. F-1 l am a general contractor and 1 ❑ I am a employer p Y er with 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working or me in an capacity. employees and have workers' g y :. 9. ❑ Building addition [No workers' comp. insurance comp.insurance. required.] 5• ❑ We are a corporation and its 10.❑ Electrical repairs or additions i.❑ I am a homeowner doing all work officers have exercised their l l.❑ Plumbing repairs or additions myself. o workers' com right of exemption per IVICiL ? y [N p. 1. ❑ Roof repairs insurance required.]` c. 152, ysl(4), and we have no employees. [No workers 13❑✓ Other Pool comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. r 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 fir my employees. Below is the policy and job site information. Insurance Company Name: Insurance Center of New England Policy# or Self-ins. Lic.#:WPA0382194-13 Expiration Date:04/01/2016 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 wilder 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 S250.00 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 herehy certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: OAVj Date: Phone#: (413) 594 666 Official use only. Do not write in this area, to be completed by city or town gfficial, 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 th City of Northampton 212 Main Street, Northampton, N A 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: The debris will be transported by: The debris will be received by: Building permit number: Name of Permit Applicant Date Signature of Permit Applicant City of Northampton Massachusetts W: 7� `1 •6 DEPARTMENT OF BUILDING INSPECTIONS M 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 backfill), sonotube holes (before pour) a rough buildinq 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 a ins ectio r made I' V�r 4 ' 5 understand the above. (Hom ne /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone M Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ 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.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. tHo meowners 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 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 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.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable £ Name of License Holder: License Number Address Expiration Date Signature Telephone 9.Re istered Hom inP�ovement 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. 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 d Local onin L ws and State of Massachusetts General Laws Annotated. Homeowner Signature. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 171 Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [CJ Siding [❑] Other[❑] Brief Description of Proposed ����% Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa:If New fiotase'and olr'addition toYexistilnq,housttiq, complete the.followinq: 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 l 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. Prin a Signature of Owner gent Date . , Section 4. ZONING AtI.Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning Th�is colunin to be filled in by Building Department Lot Size Frontage Setbacks Front Rear Building Height Bldg.Square Footage 01'0 Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces (volume&Location) A. Has a Special Permit/Vaharce/Fi riding ever been issued for/on the site? x~� �~� NO �~«_� YY �_�� DON7KNO YES «�� IF YES, date � ' 'L______—_—_- IF YES: Was the permit recorded at the Registry ofDeeds? NO �� K j DONTKNOYY YES �� IF YES: enter Book Page and/or Dncument# B. Does the site contain abrook, body of water orwetlands? NO 0 DON TKNOY 0 YES 0 IF YES, has permit been or need to be obtained from the Conservation Commission? Needs to be obtained -��~\ Obtained x-~�� Date |ssued' � � ' . C. Do any signs exist on the property? YES «_� NO v���� IF YES, describe size' type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0 IF YES, describe size' type and location: | E. Will the construction activity disturb(clearing, grading, excavation,orfi||ing)over 1 acre orioit part nfa common plan ' that will disturb over 1acre? YES NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. / / S ` v {� n(� �DeparfFmeht use ont�r ° r F t o'iii ity of Northampton P�eT r►)t .ryx,-WV�j uN,,yt�� S'�T�1`��IF r �.Xi L{.T }N v�y�i' - .sir 8R ^t uk y h�ia,�=i t Teti t }p e,'JSa ray i�. l�rsr -ktit L. ilding Department ctlrla cut�Drfrtewa Perrrtrt f t x+ n 4 i tit MAY 12 t1's5 12 Main Street :Sewer/$ep1.61.11,lrabltttX k�,�Y Y E _ r Room 100 UVate�%ttttelEAvatlablht�X r ampton, MA 01060 Two Sets Af stilckural Ptaps' �M ------ &Gas inspe Etectnc,plumping s 7-1240 Fax 413-587-1272 P150.9ite Planes` " North amp r ton, µ r r a Othe�rSpec�fftt r , , ."Y _ _. ..........._. APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE,INFORMATION Thts section to be,completed by office 1.1 Property Add ss: V Q Zone Overlay District ° f� Elm St District __ CB Dlstnct SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT:: 2.1 Owner of Record: " /- 0C Name(Print Current Mailing Address: �. 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 ermit applicant 1. Building (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 6. Total=0 +2+3+4+5) Check Number This Section For Official Use'Onl Date Building Permit Number: Issued: Signature: Building Commissionedinspector'of Buildings — Date h-v b File#BP-2015-1100 q� � Poo S SJV APPLICANT/CONTACT PERSON HOOVER MARK '2 P� � ADDRESS/PHONE 60 FOX FARMS RD FLORENCE01062(413)584-0605 PROPERTY LOCATION 60 FOX FARMS RD MAP 17A PARCEL 153 001 ZONE URA(100)/ THIS SECTION FOR OFFICIAL USE ONLY: I PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT it Fee Paid ZZ I Building_Permit Filled out � Fee Paid T_vneof Construction: INSTALL 2F ABOVE GROUND POOL New Construction Non Structural interior renovations Addition to Existing- Accessory Structure Building Plans Included: Owner/Statement or License 111889 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 r 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. 60 FOX FARMS RD BP-2015-1100 GIS#: COMMONWEALTH OF MASSACHUSETTS Ma:Block: 17A- 153 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-2015-1100 Project# JS-2015-002081 Est. Cost: $10398.00 Fee: $30.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: TEDDY BEAR POOLS & SPA 111889 Lot Size(sq. ft.): 15855.84 Owner: HOOVER MARK Zoning: URA(100)/ Applicant: HOOVER MARK AT: 60 FOX FARMS RD Applicant Address: Phone: Insurance: 60 FOX FARMS RD (413) 584-0605 O Workers Compensation FLORENCEMA01062 ISSUED ON.511812015 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL 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 Sisnature: FeeType• Date Paid: Amount: Building 5/18/2015 0:00:00 $30.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner