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24A-039 POOL M Z The Commonwealth of Massachusetts q y D° Ic Board of Building Regulations and Stans FO iar 3a] Massachusetts State Building Code,780�1 4 2 �� C ALITY E z Building Permit Application To Construct,Repair,Renovate<?i�� evil Mar2011 N One-or Two-Family Dwelling 701, s o m This Section For Official Use Only o Build' g Permit Number: •� Date Applied: z Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.2 Assessors Map&Parcel Numbers 48 Blackberry Lane LT 1.1a Is this an accepted street?yes ✓ no Map Number Parcel Number 13 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:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Lone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' Kiley & Wess "awall - Okeefe Northampton, MA 01060 Name(Print) City,State,ZIP - 48 Blackberry Lane 805-223-0340 leneratorc(dNahoo.com No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units I_N_ P001 no 4p4m,id Poem 18' x 52" Arn�OV�. �2o��J QDdt- l8 x Z �' SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.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:$ Check No. Check Amount: Cash Amount: $ 1 ❑Paid in Full 13 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. SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft. R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC RoofinR Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Tele one Email address D Demolition 111889 02/08/2021 Teddy Bear Pools & Spas HIC Registration Number Expiration Date HIC CompanyName or RIC Registrant Name 41 East Street scotta(&,teddybearpools.com No.and Street Email address Chicopee, MA 01020 413-594-2666 Ci /Town State ZIP Telephone SECTION 6: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..........El 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 8e Spas to act on my behalf,in all matters relative to work authorized by this building permit application. T Q=l.t`ll CAt.0�11G I.L�O�krYv� - 10 - Z lectronic Signature) 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 my knowledge and understanding. Scott Alexander 4/27/2020 lectronic Signature) NOTES: 1. 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(HIC)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 www.mass.bov/oca Information on the Construction Supervisor License can be found at www.mass.gov/&s 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" The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TAE PERMITTING AUTHORITY. Applicant Information Please Print Letdbly Nance(Business/Organization/Individnal):Teddy Bear Pools & Spas Address:41 East Street City/State/lip:Chicopee, MA 01020 Phone#:413-594-2666 Are you an employer?Check the appropriate box: Type of project(required): I.E]I am a employ00 er with 1— employees(frill and/or part-time).' 7. ❑New Construction 2.a I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp,insurance required.] 9. • ❑Remodeling 9. ❑Demolition 3.[-�lam a homeowner doing all work mysa[No workers'comp.insurance required.)t 4.FJI am a homeowner and will be hiring contractors to conduct all work on my property. I will 10[]Building addition ensure that all contractors either have workers'compensation insurance or are sole I L E]Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.n We are a corporation and its officers have exercised their right of exemption per MGL c. 14 0 Other P001 152,§1(4),and we have no employers.(No worlam'comp.insurance required.) 'Any appl icaut that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors roust 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:HUB International New England Policy#or self-ins.Lie.#:CPL 8665062 __ Expiration Date:04/01/2021 Job site Address: 48 Blackberry Lane City/State/zip:Northampton, MA 01060 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 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 hue and correct S'- ature:Scott Alexander Date: 4/27/2020 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.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: TEDDBEA-01 '4�RCl CERTIFICATE OF LIABILITY INSURANCE DATE �IM 12020 n 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 have ADDITIONAL INSURED provisions or be endorsed. H 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 'CRA?CT - - HUB International New England LLC PHONE FAX 1070 Suffield Street c No Ext):(800)243-8134 AIC No:413 731-9539- AIL Agawam,MA 01001 INSURER(S)AFFORDING COVERAGE __NAIC! . NSUReR A Central Insurance Compamf 20230 _ INSURED INSURER a:Arbella Protection Insurance Company 17000_ _ Teddy Bear Pools Inc. IN RERC: i 41 East St W RERD: Chicopee,MA 01020 W SURER 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. Y1BR TYPE OF INSURANCE ADDL BR POLICY NUMBER POLICY EFF POLICY EXPLTR LIMITS A X COMMERCIAL GENERAL UANUTY EACH OCCURRENCE 1,000,000 CLAW MADE FX]OCCUR CLP 8665062 4m2020 4h/2021 =TORENTED S 300,000 _ o EXP Ww cnspersor10,000 PERSONAL IT,ADV INJURY 1'000'000 AGGRE� CT (I LLIMITAPPLkS PER: StENERAL A REGATE 2,000,000 FTFOLICY JE _JI LOC PRODUCTS-C0WQP 2,000,000 THER: _ B AUTOMOBILE LIABILITY C,OIrBINEDSNGLE LIMIT 11000,000 (Ea ANY AUTO ; 1020085353 711/2019 711/2020 BODILYINJURY(Par oersord OWNED SCHEDULED AUTOS ONLY X AUTOS BODILY INJURY(Per socidard X-1 AUTOS ONLY X ANOo� rii�r PROPERI AGE—__ A U BRELLA LIAR OCCUR PEACCH OCCURRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE DED RETENTION= IT A WORKERS COMPENSATION X PER AND EMPLOYERS'LIABILITY ER — ANY PROPRiETORIPARTNER/EXECUTIVE YIN WC 8665063 4/112020 41112021 EACH A IDENT S00'� OFFICER 7�MBER EXCLUDED') a NIA I SN0� 1 M yes n describe mer I E.L.DISEASE_EA EMPLOYE SKOW DESCRIPTION OF OPERATIONS below E-POLICY UTAIT DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached N mors space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, For Verification of Insurance Purposes Only ACCORDANCE WITH THE POLICY PROVISIONS.NOTICE WILL BE DELIVERED IN AUTHORIZED REPRESENTATIVE - - ACORD 25(2016103) ©1988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Teddy Bear Pools, Inc. r 41 East Street • Chicopee, MA 01020 (413) 594-2666 & (800) 554-BEAR FAX (413) 598-8823 Home Improvement Cont. MA*11889/CT#520951V,! 6E 50 TEDD AAPOOLA.CUM `�`��`• Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation TEDDY BEAR POOLS&SPAS INC Registration: 111889 41 EAST ST Expiration: 02/07/2021 CHICOPEE,MA 01020 Update Address and Return Card. SCA t C, za+t-os;t i MAR STATE OF CONNECIl'WUT 4 DEk'AR'fl M 9,'1NT OF C0NStJMj,jj >Pt3OTECITR0 N z tic it 1,_nonv11 That TEDDY BEAR POOLS INC Q . 41 EAST ST CHICOPEE, MA01020-2605 ,r has satisfied die qualifications required by Jaw and is hereby registered as a HOME IMPROVEMENT' CONTRACTOR '#} Registration # HIC.0520951 .i.. 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Above Ground Pool Plot Plan ,�, r, %►si t%- The plot plan below is approximate measuremen r the\pool placement at the home of: Customer Info: -J O �K )c' 12- -J�3 k A ()eco�I, In the City/Town of: Z e'- Above groun of set backs arc: �' of House side_�Rear _—Septic- Leach Field Draw out you backyard including the back of your home and t lines.Show measurements from lot lines,both sides and rear as well as from the back of th ouse. (See example on back of page). This plan was completed by: Date: 41 East Street - Chicopee, MA 01020 • (413) 594-2666 - (800) 5S4-13EAR • www.teddybeirpool,,.com