16B-042 (2) 273 NORTH MAIN ST BP-2017-0063
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 16B -042 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-2017-0063
Project# JS-2017-000115
Est.Cost:$12000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: TEDDY BEAR POOLS & SPA 111889
Lot Size(sq. ft.): 23043.24 Owner: BUSONE CHAD&JENNIFER
Zoning: URB(87)/ Applicant: BUSONE CHAD & JENNIFER
AT: 273 NORTH MAIN ST
Applicant Address: Phone: Insurance:
273 NORTH MAIN ST (413) 364-3789 O Workers
Compensation
F L O R E N C E MA01062 ISSUED ON::7/21/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 24' 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: 01: 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 7/21/2016 0:00:00 $40.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0063
APPLICANT/CONTACT PERSON BLISONE CHAD&JENNIFER
ADDRESS/PHONE 273 NORTH MAIN ST FLORENCE01062(413)364-3789 0
PROPERTY LOCATION 273 NORTH MAIN ST
MAP I6B PARCEL 042 001 ZONE URB(87)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT �,�t,��
Fee Paid i%SI `Pn'
BuildingPermtt Filled Out
Fee Paid
T eaf onstruction: INSTALL 24'ABO'GROUND POOL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plan Included:
Owned Statement or License 111889
3 sets of Plans/Plot Plan
THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF MATION 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 j�/tom..
I
Signature Building Official Date 7� 1
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.
The Commonwealth of Massachusetts
TTT1�s��tGG,{�i1W Board of Building Regulations and Standards FOR
ft MUNILI
Massachusetts State Building Code,780 CMR USE TY
0 bo [3 ii Building Permit Application To Construct, Repair,Renovate Or Demolish a Revised Mar 2011
Lii n i .: One-or Two-Family Dwelling
Elj I ::: This Section For Official Use Only
Ili _.. ......... �.....
0 - B xi ting Permit Number: Date Applied:
w
C =
rBu(ding Official(Print Name) Signature v Date
SECTION I:SITE INFORMATION
1.1 Pro erty Ad ess: 1.2 Assessors Map& Parcel Numbers
. a1: __ _n. ente --
I.la Is this an accepted street?yes n_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(MGT c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside blood Zone?
Public% Private❑ _ Check i('vesO Municipal 0 On site disposal system 0
SECTION2: PROPERTY OWNERSHIP'
2.1 Owners of Record:
Jennifer 1- ChA _M one Florence ; - OiOG2-
Name(Print) City.State,ZIP r
a'i3. N /slain Sf. 413-36`j- 37$n J (enbusoncttkkao ,cowt
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building❑ Owner-Occupied 0 Repairs(s) 0 Alteration(s) ❑ Addition O
Demolition 0 Accessory Bldg.0 Number of Units __ Other El Specify: Pool
Brief Description of Proposed Work': Above Ground Pool
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: _�Q
6.Total Project Cost: $ /'lt 0 d (} Check No.11 Check Amount.. j},IV Cash Amount:
tT 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSI.Holder
List CST Type(see below)
No.and Street Type Description
Il Unrestricted Buildings up to 35,000 cu.ft.)
Cityf R>wn.State,ZIP _ R Restricted l&2 Family Dwelling
® Mason
Roofgl'fivering
W'S Window and Siding
SF Solid Fuel Burning Appliances
_ _ 1
Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
111889 02/08/2017
Teddy Bear Pools & Spas
HIC Registration Number
HIC CompanyName or HIC Registrant Name '.. Expiration Date
41 East Street
No.and Street Email address
Cicopee. MA 01020 _ 413-594-2666
City/Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.CL 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_......_❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize Teddy Bear Pools& Spas
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER%OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of'n'y knowledge and understanding.
Stephen Otto
-- t— --......... .__.—
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HRC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
ectv,v.niass.eoo:oca Information on the Construction Supervisor License can be found at www.mnss.gov:dos
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
4,.,',,, ,,, The Commonwealth of Massachusetts
Department of Industrial Accidents
* '{' Office of Investigations
I -rh
�v
to600 Washington Street
`� , Boston, MA 02111
-cl
t...7-2H-4-4' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeEibIv
Name(Nusiness/Organizvtionhndividual):Teddy Bear Pools & Spas
Address:41 East Street
City/State/Zip:Chicopee, MA 01020 Phone#:413-594-2666
Are you you an employer?Check the appropriate box: Type of project(required):
1.I— I am a employer with 100 4. ❑ I am a general contractor and 1
employees(full and/or part-time).* have hired the sub-contractors 6. 0 New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees 'These sub-contractors have g. ❑ Demolition
workingfor me in anycapacity. employees and have workers'
P Y 9. 0 Building addition
[No workers'comp.insurance comp-.a cornca-
required.] 5. 0 We err.a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MOL
12.0 Roof repairs
insurance required.]` c. 152,§1(4),and we have no 131 it cher P001employees. iNo workers' i_I
comp.insurance required.]
`Any applicant that checks box al must also fill out the section below showing their workers'compensation policy information.
'Homeowners who submit this affidavit indicating they arc 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 nM state whether or not thaw entities have
employees. it the sub-contractors have employees,May must provide their workers comp.piney number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the polity and job site
information.
Insurance Company Name:Acadi Insurance Compay
Policy#or Self-ins. Lie.e:' II WPA(01382194-14 Expiration Date:04/01/2017 ^
Job Site Address: ( N13 . /"I A-1 A Sf cityistateizip: HO r e.n.e ,kt 0104' ?--
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 font 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
Sianature: Stephen Otto Date: ...
Phone#: (413) 594-2666
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
. Contact Person: Phone#:
P ._
Above Ground Pool
Plot Plan
att.
TEDDY BEAR POOLS C SPAS 1 *zit
The plot plan below is approximate measurements for the pool placement at the home of:
r
Customer info: den n( el/Ch44 1))1/1SOIIe & 3 H , Mout S '
In the City/Town of: FioreMre AAA i 0/6(p,9—
/
Above ground pool set backs are: of House Side Rear Septic Leach Field
Draw out you backyard including the back of your home and lot lines. Show measurements from lot lines, both sides and
rear as well as from the back of the house. (See example on back of page).
This plan was completed by: Date:
9 i
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