42-027 (3) 795 WESTHAMPTON RD BP-2019-1031
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:42.027 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: Above ground Pmol BUILDING PERMIT
Permit# BP-2019-1031
Project# JS-2019-001689
Est.Cost:$6000.00
F 0.0o PERMISSION IS HEREBY GRANTED TO:
Cons!Class: Contractor: License:
Use Group: TEDDY BEAR POOLS & SPA 111889
Lot Size(sp.in28662.48 Owner: BLAIS RAYMOND&ROSEANNE RISER
Zoninw Applicant: TEDDY BEAR POOLS & SPA
AT. 795 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
41 EAST ST (413) 594-2666 0 Workers Compensation
CHICOPEEMA01020 ISSUED ON:4/412079 0:00:00
TO PERFORM THE FOLLOWING WORK.•REMOVAL OF OLD ABOVE GROUND POOL AND
REPLACE IN SAME SPOT, SAME SIZE WITH NEW
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: Qi Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. n
Certificate of Occupancy Signature: 2
FeeType: Date Paid: Amount:
Building 4/420190:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
-e "1;1( C472-le ?'o
File R BP-2019.1031owl I"
APPLICANT/CONTACT PERSON TEDDY BEAR POOLS&SPA &— "
ADDRESS/PHONE41 EAST ST CHICOPEE (413)594.26660
PROPERTY LOCATION 795 WESTHAMPTON RD
MAP 42 PARCEL 027 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Tvpeof Construction: REMOVAL OF OLD ABOVE GROUND POOL AND REPLACE M SAME SPOT,SAME
SIZE WITH NEW
New Construction
Non Structuralinterior 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
INPORMATION PRESENTED:
I_/ 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 Cm 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 Sump Water Management
—Demolition Delay�J
I",Q 3Zo1
Signature of Building Official IDate
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all cooing
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
s Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Plaming&Development for more information.
'sAid cUp hr_
The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Massachusetts State Building Code,780 CMR MUNICIPALITY
USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Moi�2011
Otra-or Two-Finaily Owel1mg
This Section For Official Use Only
Building Permit Number: Date Applied:
BmMkg Officid(Print Name) Sigmmre Date
SECTION l:SITE INFORMATION
1.��party A9dras)4/n-� V KP is Af-1- Map&Parcel Nsmben�17
Us Is this a r- stmt?yes ✓ no Mvp`Number Pwocl Number
13 Using lidis mations IA Properly Dmessiom:
Zoning District Proposed ulna I.m Area(sq R) Frontage(8)
13 Balldisg Setbacks(11)
From Yard Side Yards Rew Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(htG.L c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public O Private O Zc . — (bstsde Flood Zan? Municipal O On sire disposal system O
Check if yesl3
SECTION 2: PROPERTY OWNERSHIP"
2.1 Owner"of ,
11,4y 1j 14 "Renr�tA.4)s NoRrl+41+ 7T-DN 06a
Nese(Print) Coy.Smc,ZIP
77a ';�t> 4&3- P76-0603
No.and Strad Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(dealt a0 that apply)
New Construction O Existing Building 0 O.-Occup d ❑ 1 Repairs(,) o 1 Ahemion(s) O 1 Addition 0
Demolition O Accessory Bldg.0 Number of Units I Other p✓ Specify: POOH
BriefDesu:riptlon offhoposed Work': SWIMMING Pool
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building f 1. Building Permit Fee:S Indicate how Ice is determined:
0 Standard Cityflbwn Application Fee
2.Electrical S 0 Total Pmject Cost'(Item 6)x multiplier x
3.Plumbing f 2. OmerFees: S
4.Mechanical (HVAC) S List:
5.Mechanical (Fire S Cash A
Taal All Fns:$
S ion
CTedc Nga�1 Check Amom : LLd morous_
6.Total Project Cost: I S � � 0 Paid in Full 0 Outstanding Balance Due:
Here is your Permit information
Apply for your building permit with your city/town. The permit
application must be posted.
Please
• Call Dig Safe - (Massachusetts: 888-344-7233 / Connecticut: 800-
922-4455). Typically, there is a 3 day waiting process once
contacted before you can dig.
• Get in touch with your electrician - give an idea of general time
frame to them. The electrical work should be done soon after the
pool is installed (within a couple of days).
• Contact your insurance company. It is a good idea to ask about
adding your pool to your insurance coverage in the event of a bad
winter with heavy snow load.
Above Ground Pool
Plot Plan
The plot plan below is approximate measurements for the pool placement at the home of:
Customer Info:
r
In the City/rown of:
Above ground pool bk;,arg of House Side Rear Septic Leach field
,,
�d
i
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:
41 East Street • Chicopee, MA 01020 • (413) 594-2666 • (800) 554-BEAR • www.teddybearpools.com
� �• 7� �po�nanzoozcvP,a,�,�� o�C-/ czc�,ti.��
Office of Consumer Affairs and Business Regulation
10 Parc Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
_ - Trp. crrvnremn
Regisha9an: 111889
TEDDY BEAR POOLS&SPAS INC---:,-, ...__ i t:xprabw: 02M7/2019
41 Fast St - _ -
Chicopee, MA 01020
Up eAaMrm aMeM urO. U"reran for dv .
- n, o suan•,n r,
STA3 E OF CONNECT1'CUT ,A 66-AgTMEYT OF CO'N5. , R P40j ! 3�
Be'It lvouv[hat - - -
TEDDy E E POOLS INC
41 EASTrST
CHICOPEE, MA 01020-2605
is certified by the Department of Coms 'm Protection as a registued
I ;+
HOME IMPROVEMENT CONTRACTOR `
Registration # HIC.0520951 +I
je EfTecuve, 72/di/2017
Expiration: 11/30/2018 � N .
SECTIONS: CONSTRUCTION SERVICES
SI Constrwoen Saptaviser Licerue(CSL)
Liame Number Expiration Dale
Name of CSL Holder
List CSL Type(see below)
No.and Sired Type Deserwhon
U Unrestricted QkildingstT to 35,000 ca.%)
R Restricted 1&2 Family Dwelling
City/Ibwo,State,ZIP M Masonry
RC gooft Covering
WS Window and Siding
SF Solid Fact Burning Appliances
I Imulatioo
le Email address D Demolition
5.2 Registered Home Improvement Cmtmcfor(IHC) 111889 02/08/2019
Teddv Bear Pools &SDas MC ReVsmama Number Expiration Daft
HIC C Nie or HIC Regiment Name
41 East Strut
No.and Street Email address
Chiaooee, MA 01020 413-594-2666 J)t &L;s, ✓ -
Cityfrown,State ZIP Teleykne
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT QWG.L c.1S2.§2SC(6))
Workers Compensation Insurance affidavit must he completed and submitted with this Application. Failure to provide
this afBdavft will result in the denial of the Iswance of the building permit.
Signed Affidavit Attached? Yes..........C) No...........O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner ofthe subject property,hereby authorize Teddv Bear Pools& Silas
to act on my behalf.in all matters relative to work authorized by this building permit application.
Print Owner's Name(F.kx:tmnic Sigrntare) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby anent under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
TED HEBERT
Print Owners or Authorized Agent's Name(Electronic Signature) Dae
NOTES:
I. An flamer who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nor registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
prW"or gtwanly fund under M.G.L.c. 142A.Other important information on the HIC program can be farad at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www mass.e(,v/tins
2. When substantial work is planned,provide The information below:
Tota Boor area(sq.ft.) (including garage,finished basement/attics,decks or punch)
Caoss living area(sq.ft.) Habitable room count
Number of Breplaces Number ofbedrooms
Numberof bathrooms Number of half/baths
Type of heating syst® Number ofdedrs/porches
Type of cooling system Enclosed Open
3. "Taal Project Square Footage-may be substituted for"Taal Project Cost-
The Commonwealth ofMassaehusetts
Department of IndustrialAcridents
I Congress Street,Suite 100
Boston,Mal 02114-2017
www.massgov/dia
ww.rkers'Compemadon Insarsaee Affidavit:Builders/Contme rs/P•IeetridaosM%mbers.
TO BE FILED%TrH THE PERMFM'XG AUMORrIY.
Applicant information Plisse Print Ledth
Name 03man-vo gars conedi-dead):Teddy r Pools& Spas
Address:41 East Street
City/State/7,ip:Chicopee, MA 01020 Phone#:41&594-2666
Areyaaaa emplayar!t etk the appr6pri+u ba: none[
Type of P 1 (R9n+red:
1�Iam eempl%cr with 100 eorployrn(fWlmWor part-pmol.• 7. ❑New construction
2.❑Imnamie popimmmparmership mid havemempl%ar wwkirrg
fix.. g. ❑Remodeling
am cqa' rvv IN.workers'camp.inpn . requ ced I
3.❑Iamab caner doing all wink myxlf INo workaiwmp,umnaro raluuad.j t 9. ❑Demolition
e.❑I am aMmeownar aM wdl he toinG coritrstwa m cddun eU wink ov my popery. 1 coal 10❑Building addition
creme then ell mptr¢tmsaithm have wwk ".rupmaaaceoi vn or.rule 11.❑Electrical repairs or additions
pWr orswithroernpbyxs.
12.QPilmb-g repair;or additions
5c]I am a gwasl codhn ba,ed 1 haveeirw daveb ktramors ,ir,a de ddchal clan
These subconbecxors love empl%res and have wmkeri camp.insmencc.: 13.❑R[gfrepays
6.❑We mea corpormonaod as afwsbave esdtssed acts ngN ofe¢mptan per Mot, ME10111hW P001
152.11(4),erd we hive m emplatea INowwtass-awn,nssumraa regmM]
•My appliwdtlut checks W.#1 mum also fill od the xenon helow showing their wdkers'mmpndtm polity iofareat e.
t Homeowncsaha submit shbaff gait iMicau,rhry de doingall work and clan hocoutride conhaatars mum araea newafhd it mdmadng awls
9�1W clack thisb rnum citrated a additolul shut shaving da nave dtha suhmntreomrsmines,wiidheror M dhaa atilirs have
earyloyar. Elea abconhurms Meempl%as,they mots ppvide thea workers'ua poli%mwba
I sur an employer that u providingworkers'compensation insurance for my employees. Below is the policy and job site
-formation.
Insurance company Name:Acadia insurance Company
Policy#or Self-ins.Lie.#:W PA0382194-16 _ Expiration Dow:04/01/2019
lob Site Address: City/statarzip:
Attach a copy of the workers'compensation polity declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to 31,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a SNIP WORK ORDER and a fine of up to 5250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insusence
coverage verification
I do hereby mtify ander thepains ondpenalSes of perjury that th formadonprovided above is true and mrr[G
S�� TED HEBERT Date__
Phone#: 413.594-2666
Offrdd we only. Do not write in this area to be corrgderedby dry or town official.
City or Town:— Perm]t/License#
issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/town Clerk 4.Electrical fuspector 5.Plumbing Inspeemr
6.Other
Contact Person: Phone#:
---IN TEDDBEA41
ACRO CERTIFICATE OF LIABILITY INSURANCE
THIS CERTIFICATE IS ISSUED AS A MATTER OF BIFO TION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFRR TIVELY OR NEGAT RELY AMEND, (WEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUINGINSURER(SI,AUTHORRED
REPRESENTATNE OR PRODUCER AND THE CERTIFICATE HOLDER
IMPORTANT: B the c*rMB holder ben ADDITIONAL INSURED,the peNCYLhe)I hm AOgTiD INSURED proNNbRs a 9eeMorpeO.
If SUBROGATION IS WAIVEO, subject to the tent and conditions of tM pelky,cerlaln pPIMN may Nqulrs an enEaeement. A st[hnNnl OR
SIh.0run le does not ton%r d"to the corulkate hoMa Ix See W such
PROgREA WT
Insurance Center of New England,Inc 'SFA[ ---
1070 SUMe1d SI/eet a EMI:l600j 24Bd120 Pm.a j(413)7314539
Agawam.MA 01001 ss: — —
_ .[NMR[luF'mwatd[FAa[ _ and,
.MWMAA:A"dlalmunM Cmpany
�RTo rasaEx
ALL AMERICA -20M
IRs
Toddy Bear Pools Inc. MaRFRc
N East St
Chicopee,MA 01020
NALREA E: _ +__—.
_ Wx11EfIF: _ _ I
COVEM TIFICATE NU REVISIONNUIRSER
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOWHAW BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT. TERM W CONDITION OF ANY CONTRACTOR OTHER DOCUMENT MAM RESPECT TOWNSON THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SU&IECTTOALL THE TFAYS.
E%CLUSIOINS NIDCDNUTIONSOSUCH POLICIES LIMBS1 MAYNAVEBEENREONCEOWPMCWMS.
M61R. lYR6MMXLE Alan.We" PoI/LY MNYBEX_ INl m" 'I UBra _
A % CDEYaC1YOMBALIMYIIY E.Y.N.FNE 5 1'wo'm
a GA.MMME , 1(,acus cvAD25rebv wmlmu OID113pt9 PREM.&iO RENTED 200.000
l .s
__ Y[o EIw 4Nrvow Fwml s 6,000
jai- —__ _. PEasuruL aAEw NARr
$ 1.g00.ODO
M MYyRMIF LgFRM��Ir MVEBPFIL GEIERALA EWE s 2ON.000
FIB= �NEDt LM MfCDICTS�CCMP.OnA L 2P�'�
B MIIOYOML WBaIIY
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MgR.TO 5�1(gAEO BAP 9855061 07101/2018 07ID112019 eODAr INAIRr IiW Y'Rnl .a ___.
M1fOSDILr % Wll6 IECMr NAF�IILIAWmORi)
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A �wpINMs IIDN %
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YIN WPAOJ82191-t7s 500,000
XXyyeen�OsNnYb EL DRFABE�FAEMPLOEEf �'
�SOpINa1�OPFR.111CNSeaYR El 06FbE.RIICrIWII S 000
aSLRPTKW a 01BMMN!/LOCAlFa41M3eMB ACtlW M.YbW Rwn.Af StAyaI.gMFaF?FFaele7FsxwElYy
CIERTMATE HOLDER
TO[hOW WMIMa Of CWer/ge.
CANCE"TIONN
SNDULD ANY W THE ABWE OE9CRMED POLICIES BE CAdICw R Pn BEFORE
For Verification of bnurance Purposes Only KWROAICE DATE
ATTHEREOF, NOTICE
HEEONOTICE YIAL OR DELIYPRED M
ABnMR®AFNRSrtARs
ACORD 25(2 016102) O 19562015 ACORD CORPORATION. AN TWAS IBBerYaO.
The ACORD name and logo ale registered marks DI ACORD
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for thein employees.
Pursumt 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 ajoint 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 appurtenmt thereon 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 ficense 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 my of its political subdivisions shall
enter into my contract for the performance ofpublic work until acceptable evidence ofcompliance 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-commctor(s)mantels),asklms(es)and phone number(s)along with their eeddicate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not requited to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is nequired. Be advised that this affidavit my be submitted to the Deparuncot 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 my 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.
Gly or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space us 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 pemrit/license number which will be used as a reference number. In addition,an applicant
thin must submit multiple pemdiNcense applications in my given year,need only submit one affidavit indicating current
polldy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or
town)."A copy ofthe affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof than a valid affidavit ism file for forma permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citir®is obtaining a license or permit not related on my business or commercial venture
(i.e.a dog license or permit to bum leaves em.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston,MA 02114-2017
Tel.#617-72711900 ext 7406 or 1-877-MALSSAFE
Fax#617-727-7749
Revised a2-23-15 www.mass.gov/dia
4/42019 BLAIS AG PERMIT INFO 001.Jpg
City of Northampton 212 Main Street,Northampton, MA 61060
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: 71S C✓='I rNa/o��a-J 'd?.n
The debris will be transported by: %fear
The debris will be received by: 10 'Q G!QR FOOL< WAQQN M-R.
Building permit number:
Name of Permit Applicant
Date Si ature of Permit Applicant
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