42-142 (5) 1075 WESTHAMPTON RD BP-2019-1449
GIS# COMMONWEALTH OF MASSACHUSETTS
MM:Block:42- 142 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildino DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:Above around pool BUILDING PERMIT
Permit# BP-2019-1449
Project# JS-2019-002353
Est Cost,$3500.0
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
const.Class: Contractor: License:
Use croup: Homeowner as Contractor_
Lot Size(sa, R.): 105850.80 Owner: SIMMONS BLAKE E&LYN M
Zoning, Applicant: SIMMONS BLAKE E & LYN M
AT: 1075 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
1095 WESTHAMPTON RD (413) 586-6585 ()
FLORENCEMA01062 ISSUED ON.612012019 0:00:00
TO PERFORM THE FOLLOWING WORMSEMI IN 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 OccuoancY Signature:
FeeTvae: Date Paid: Amount:
Building 620/20190:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File R BP-2019-1449
APPLICANT/CONTACT PERSON SIMMONS BLAKE E&LYN M NUTTELMAN
ADDRESS/PHONE 1095 WESTHAMPTON RD FLORENCE (413)586-6585(1
PROPERTY LOCATION 1075 WESTHAMPTON RD
MAP 42 PARCEL 142 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
REQUIRED DATE
ZONING FORM FILLED OUT EN
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: SEMI IN 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 FWING 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 Cul 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 Commince
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
/
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.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sevrer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/SBe Plans
40 Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 7 -SITE INFORMATION
1.1 Property
yrAddress:
� r,` ,,((jj�� ���� ,,,,�� This section to be completed by office
1075 W(ShIck OL)VA TMck Map <10 Lot /`� Unit
LOla a Zona Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
LyyL + Blau.e Simwwokc, 105 weshhavy�piun2c(IF( o�vvr�a
Current Mailing Address:
Tewphone� aaa a 3�n
Sigrature
2.2 Authorized Agent:
Name(Print) Current Meiling Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
COMIDletedb permit applicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 8
3. Plumbing Building Permit Fee
04. Mechanical(HVAC) O
5.Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For DRICIal Use Only
Date
Building Permit Nu r. Issued:
Signature: "�19
Building Commissionerllnspector of Buildings Date
�l�V1Y1" ymM eD VAS v\- " COV1/\'_
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Info rnatlon AWst Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
--, � rtl -� � I Build.,Depsomenr
IJ
Lot Size — ,=i.t— EEI l I
Frontage 0
Setbacks Front
Side L:O R:0 Lf R:= 0
Rear Cl
Building Height ✓,f S
Bldg.Square Footage
Open Space Footage o
(Iur area minus Wit&paved
him )
#of Parkin Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO (D- DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Bcok F Page' and/or Document#r
B. Does the site contain a brook, body of water or wetlands? NO a DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained IO , Date Issued: O
C. Do any signs exist on the property? YES O NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO (D--
IF
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 O NO
IF YES,then a Northampton Slorm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicablel
New House ❑ Addition ❑ Replacement Windows AKeration(s) Q Roofing
Or Doors D
Accessory Bldg. ❑ Demolfilon ❑ New Signs [01 Decks (17 Siding[1-31Other(q
Brief Description of Proposed
Work: i r s F0,l proposed
FT-VJ, d F $GVVt i i ^� V-V-A A �00 I
Alteration of existing bedroom_Yes No Adding new bedroom Yes No
Attached Na native Renovating unfinished basement —y"_ No
Plans Attached Roll -Sheet
ea.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 consWction. Dimensions
e. Number of stones?
I. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of constmc ion
I. Is construction within 100 a.of wetlands? Yes No. Is construction within 100 yr. floodplain_Yes No
J. Depth of basement or cellar Boor 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 To-OWNER AUTHORVATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, . 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.
nature of Owner Data
as Owner/Authorized
L�
Agent hereb 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.
- C�1� Lam+ A Si Inn Nn w`S
Print Name (�
S A A �. Ap `rti (F I s 15
Signature of t Data / —I
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address EVration Date
Signature Telephone
9.Registered Nome Improvement Contractor: Not Applicable O
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,1 45C(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...... ❑
City of Northampton
Massachusetts 0?°�
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Strut • Municipal Building
NorNavpton, M 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.C.L.Chapter 142A requires that the`reconstruction, alteration,renovation,repair, modemizao'on, conversion.
improvement, ra n ival,demolition,or construction otan addition to any pre-existing owneroccupied building containing
at least one but not more than four dwelling units...."to structures which am adjacent to such residence or building'be
done by registered contractors.
Note.If the homeowner has contracted with a corporation or LLC,that entity must be registered
Type of Work: Est.Cost:
Address of Work: i t s- S\,�+\a p�
Date of Permit Application: 1 l
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
Job under$1,000.00
_
Owner obtaining own permit(explain):
_Building not owneroccupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
1 hereby apply for a building permit as the agent of the owner:
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
caner Narne krAISignature
City of Northampton r
Massachusetts ) >•- ,r}`
e
DEPARTMENT OF BUILDING INSPECTIONS P.
413 Main Street • Municipal Building =J\ 0
Northampton, MT 01060
Massachusetts Residential Building Code
Section IIG R5.1.2
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.
Section 110.115.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 1 I O.R5,provided that if a homeowner engages a person(s)
for hive to do such work, then such homeowner shall act as supervisor.
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.
City of Northampton
0 Massachusetts
DSPABTMENT OF BUILDING INSPECTIONS
212 in str t eM icip,l Building
NOaNu t.' NT 01060 Cos
Debris 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.
The debris from construction work being performed at:
iol� WQsWW(Me(W Pc c% C/orenCd
(Please print house number a d street name)
Is to be disposed of at: rr,nn
lead B��tr CtJa.��
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
1` 1An
(Company Name and Address)
u—A /
Signature of Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
The Commonwealth ofMassachuselts
Department oflndustrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www avass.gov/dia
Workers'Compensation Insurance Affidavit:Buaders/ConWaden/Electricians/Piumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Lee§blP
Name(Business/Organization/Individual):
Address:
City/State/Zip: Phone#:
An you an employer?Cheek rhe speculative hos:
Type of project(required):
I.❑I am a employer with employe"That]and/or pun-timc).' 7, ❑New construction
A❑lama sole proprietor orpar mrship and have an employees working browns g, ❑Remodeling
any capacity.[No wmkets'comp.insurance requitedd
301 am a bemwwner doing all wwk myself.[No workerieomp.inxmsnccrwtuird.I' 9. []Demolition
4G11m abomepwner and cow be hiring contractors to conduct as wind,m my property. I will 10❑Building addition
Y7'esc urc that all contractors either have workers'compemmion insurance ar are mile 11.❑Electrical repairs or additions
proprietors with no employ.. 12.❑Plumbing repairs or additions
5C]I am a generalwat..,and l have hired the mbmntrxtors listed on theattached,lain 13.�Rtaof repairs
These mb<otr
nactn ohave employees m
attd have work 'comp.mourerue.:
G❑We are a coryontion and its officers have nxrscixd their right of exemption per MGL c. 14.❑Other
153.§I(4),wd we Imve no employees.INo workers'comp.immance rcyuirw.l
'Any applicant Nat checks box pl mmt also ill ora the section below showing[hcirworken'compensation policy infomution.
f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
TCont.m that check this box must stanched an additional sheet showing the name of the sub-contractors and state whether or not throe entities have
employees. If the sub-commnors have employees,they must provide their workers'comppolicy number,
I am an emplm•er that A providing workers'compensation insurancefor my employees. Below is the policy and job site
informaaon.
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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may he forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
Ida hereby rtify ander t pmnsand penalties ofperjury that me information provided ova is ue and correct
Si nature. S;__ Date:
Phone#: a a - a3
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Peendt/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityrrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
l
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Teddy Bear Pools, Inc.
rr 41 East Street • Chicopee, MA 01020
t Cont.MA#11899/CT
(413) 594-2666 • (800) 554-BEAR
FAX (413) 598-8823
Home l�rE� [AR"01I.s CffiM520951
�� C7//72✓J?2?✓n�i�'ll.�lL (t�✓(�L�CJ.r�rfCGl!/iGGf1P.v��3-
Office of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: Corporation
Registration: Mass
TEDDY BEAR POOLS 8 SPAS INC Expiration: 02/0712021
ESTAST AST EE, —'—
41AS PAP. 01020
Updele Address aed Remrn Card.
S➢AB'E 06 NUCFiCUIT 0 DSPART•bldrNT Of CONSUMER PROTEC'CPOIN
� .. Bc It larnw that - -
TEDDY SEAR.POOLS INC
41EAGCST
CHICOPEE, NIA 01020-2605
I as satisfied the qunlificalioas raluiredJ>y]am and is hereby Ieglstceed as a
HOME IMPROVEMENT CONTRACTOR
Registration # HIC.0520951
Effective: 12/01/2018
txpi ration: 11/30/2019
- MltM1rlle Seagull Co luianv
------------
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ACRO CERTIFICATE OF LIABILITY INSURANCE °"'411NN'e9Yn
THIS CERTIFICATE 15 ISSUED q6 A MATTER OF INFORMATION ONLY AND CONFERS NO R ALTER THE C UPON VERAGE AFFORDED B MOLDER.THIS
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BELOW. AT CEOR PRODUCER,
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Insurance Center of New England,Inc '1AYN0SEw (800)2434194 'As".(413)731-95391070 SVBiIId Street - 41 -
Agawam,MA 01001 Meal
INIUREMS)010RDINO COVEMOE _ "Re
_.. MURER A:Acadia Insurance Company
ryssafa ,wWRen s:ALL AMERICA .20222
Teddy Bear Pools Inc. novelRc:._.
41 East SI adAMl
Chloopon,101020
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COVIEFU
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THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREDNAMED ABOVE FOR THE PCRUGY PERIOD
INDICATED. NOTATTHSTANOWG ANY REQUIREMENT, TERM OR CONDITION OF AMY CONTRACTOR OTHER DOCUMENT WITH RESPECT TOVWICH THIS
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CERTIFICATE MAY SUED OR MAY PERIAK THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TOALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN MDUCED BY PND CVJmS.
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ACORD 111(20103) C 19884015 ACORD CORPORATION. All flights reserved.
The AC ORD name and logo are registered marks of ACORD