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36-313 (6) 169 CARDINAL WAY BP-2020-1196 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:36-313 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cate og_1y: inground Pool BUILDING PERMIT Permit# BP-2020-1196 Proiect# JS-2020-002004 Est.Cost: $47000.00 Fee: $75.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: 21ST CENTURY POOLS & SPAS 116579 Lot Size(sq. ft.): 18905.04 Owner: KATES DANIEL zoning: Applicant. 21 ST CENTURY POOLS & SPAS AT. 169 CARDINAL WAY Applicant Address: Phone: Insurance: 1801 MEMORIAL DR (413) 532-0100 CHICOPEEMA01020 ISSUED ON.6/4/2020 0:00:00 TO PERFORM THE FOLLOWING WORK:2207 inground pool POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. minding Inspector Underground: Service: Meter: Footinl;s: 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 Sif_,nature: FeeTvpe: Uate Paid: Amount: Building 6/4/2020 0:00:00 $75.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2020-1196 APPLICANT/CONTACT PERSON 21 ST CENTURY POOLS&SPAS ADDRESS/PHONE 1801 MEMORIAL DR CHICOPEE (41 j)532-0100 PROPERTY LOCATION 169 CARDINAL WAY MAP 36 PARCEL 313 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildina Permit Filled out Fee Paid Iypeof Construction: 2207 in round pool New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 116579 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF9,RMATION 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 63 Signature of Eruilding 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. 1 �.°'`icy�,t}��, d .. �.. .t }� i '` _ t � • r Yc .,.1 ; - F, •,+� . . . sem'f IV �yy ' Department use only City of Northampt ��j' Status of Permit: Y, Building Department Curb Cut/Driveway Permit A 212 Main8 et G/f/ `/ ewer/Septic Availability Room .1 Q?�� N9 r/Well Availability Northampton, 0 o Sets of Structural Plans phone 413-587-1240 Fax �'f;�'' -12 Plot/Site Plans ' 0 /" 1 Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, R 0 ► E o/R,6EMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office Map ? Lot (` Unit Zone Overlay District Elm St. District CB District SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: DAK'Ia- kATEL�- IVA ca-A"4', way Ti."u I'y A c1 Name(Prin Current Mailing Address: H�3- 320 -35314 Telephone Signature 2.2 Authorized Agent: %(S 4- c fu Pau/-5 c Name(Print) Current Mailing Address: o" V/3- 3a--o/(U Signature Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building �Odu 00 (a) Building Permit Fee 2. Electrical `/1 (b) Estimated Total Cost of U(!d r 4j Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total = 0 + 2 + 3 +4 +5) i Check Number 00 This Section For Official Use Only Building Permit Number: �J2— �1� - ttt C�4 Date Issued: Signature: Building Commissioner/Inspector of Buildings n Date l� EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Sizedoj"0 SQ a ld S'Q Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DON'T KNOW J YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registp of Deeds? NO O DON'T KNOW YES Q IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO CDr"" DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Q , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO 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 ® NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding [0] Other Brief Description of Proposed /n� Work: 412 12J (-75/0mi- AN Alteration of existing bedroom Yes_,K No Adding new bedroom Yes _ No Attached Narrative Renovating unfinished basement Yes o Plans Attached Roll -Sheet 6a. 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 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 as Owner of the subject property hereby authorize to act one to work authorized by this building permit application. 5/_,% 7� Signature ofcaner Date I 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. Print Name Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable kool— Name of License Holder: License Number Address Expiration Date Signature Telephone 9.Reastered Home Improvement Contractor: Not Applicable ❑ o to`J 1 "A Company Name Registration Number Address 2 Expiration Date MA Gro Telephone 7`�/,3- V,?-0/X 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....... L No...... ❑ Workers Compensation and Employers Liability Insurance Policy Insurer ID No(s): 34355 MA Retail Merchants WC Group Inc. Carrier Policy#: Policy Period PO Box 859222-9222 014005032389120 01/01/2020 to 01/01/202, Braintree, MA 02185-0000 Information Page Renewal Policy FEIN: 043001895 Carrier Prior Policy#: 014005032389119 Item 1: Named Insured and Address Agency 21st Century Solar Pools Inc The Dowd Agencies LLC 21st Century Pools&Spas 14 Bobala Road 1801 Memorial Drive Holyoke, MA 01040 Chicopee, MA 01020 Other Workplaces Not Shown Above: No Other Workplaces for this Policy Additional Named Insured: See Additional Named Insureds if Applicable Type of Business: Corporation Federal ID#: 043001895 Risk ID: 000000000 NCCI/Bureau#: 34355 Unemployment ID M File#: 014005032389120 Item 2.Policy Period The policy period is from 12:01 AM on 01/01/2020 to 12:01AM on 01/01/2021 based on the insured's mailing address time zone. Item 3. Coverage: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $500,000.00 each accident Bodily Injury by Disease $500,000.00 policy limit Bodily Injury by Disease $500,000.00 each employee C• Other States Insurance: D. This policy includes these endorsements and schedules: WC000000C(01/15), WC000313(04/84),WC000414A(01/19),WC000422B(01/15), NOE(01/01),WC200102(01/14), WC200301(04/84), WC200302A(09/08), WC200303D(08/10), WC200306B(06/13), WC200405(06/01), WC200601A(07/08) Item 4: Premium The Premium for the policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code# Premium Basis Rate Per$100 of Estimated Annual Premium Total Estimated Remuneration Annual Remuneration See Schedule of Operations on Following Page(s) Minimum Premium Prorated Premium Estimated Annual Premium Expense Constant Deposit $316.00 $ 1,893.00 $ 1,893.00 $0.00 $0.00 Issuing Office: 35 Braintree Hill Office Park Ste 206 Date Printed: Countersigned by: Braintree MA 02185-0000 12-30-2019 Form#WC 00 00 01 C (Ed. ) ©Copyright 2013 National Council on Compensation Insurance,Inc.All Rights Reserved. Page 1 of 1 Workers Compensation and Employers Liability Insurance Policy Insurer ID No(s): 34355 MA Retail Merchants WC Group Inc. Carrier Policy#: Polic Period PO Box 859222-9222 014005032389120 01/01/2020 to 01/01/2021 Braintree,MA 02185-0000 Information Page Renewal Policy FEIN: 043001895 Carrier Prior Policy#: 014005032389119 Item 1: Named Insured and Address Agency 21st Century Solar Pools Inc The Dowd Agencies LLC 21st Century Pools&Spas 14 Bobala Road 1801 Memorial Drive Holyoke,MA 01040 Chicopee,MA 01020 Schedule of Classifications : MA Code No. Classification Payroll Rate Premium 8111 Plumbers'Supplies Dealer&Dr $87,422.00 2.49 $2,177.00 01/01/20-01/01/21 8742 Salespersons Outside $46,912.00 0.12 $56.00 01/01/20-01101/21 8810 Clerical Office Employees Noc $129,623.00 0.07 $91.00 01/01120-01/01121 Description Percentage Factor Amount Manual Premium $2,324.00 Rate Deviation (9037) 20.0000% $465.00 Increased Employers Liability Limits(9807) 1.0000% $50.00 Merit Rating (9885) 0.9500 $ 1,814.00 Standard Premium $1,814.00 Normal Premium $ 1,814.00 Expense Constant(0001) $0.00 Domestic Terrorism(9740) 0.0300 $79.00 Annual Premium $1,893.00 DIA Assessment 1.3400%/ $29.00 1.3400% Total $1,922.00 Merit Rating Effective Date Payroll Rate Charge .9500 01/01/2020 Domestic Terrorism 263,957.00 0.0300 79.00 Form#WC 00 00 01 C (Ed.) 0 Copyright 2013 National Council on Compensation Insurance,Inc.All Rights Reserved. Page 1 of 1 City of Northampton Massachusetts 'I DEPARTMENT OF BUILDING INSPECTIONS x ` 212 Main Street •Municipal Building Northampton, MA 01060 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: (Please print house number and treet name) Is to be disposed of at: (Please print hame and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) 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. 21st Century Solar Pools, Inc., d/b/a POOL 21st Century Pools and Spas 1801 Memorial Drive, Chicopee, MA 01020 SALE, 21 s Century (413) 532-0100 MA Reg. #116579 • CT Reg. # 530620 AGREEMENT Pools & Spas E-mail: sales@21stpools.com Name 1)ac1 V--x oA es Date _ C4 Address C Phone (H) y k-3 _ ZO City State tk,A Zip Phone (C) Sold By Source e-mail P< p� rte; PRICE Manufacturer/ Model Name " k Zu m.oo Size ZZ3-7 Liner W Cc;OUq . oo Filter/ Pum �S %-n F,kA-(--r ►= S7 ,Q0 Ladder r Uo Chemicals Maintenance Kit ac Kit Net Brush Thermometer Test Strips) _ Options /Assesories: —\( . o.�_ �, . U p L . -- - -1-7.00 SFcxJi ` LN-XD.OG Wo OL BUILDING PERMITS are required for above ground pools in most areas as well as for an electrical work SUBTOTAL '�yo2l . OU _. y performed. The permit process will help insure a safe installation, please check with your building official for local _ requirements. Pool pump may be supplied with a cord that is not appropriate DELIVERY for your installation. It is the electrician's responsibility to supply and install an appropriate pump cord, if necessary. TAX L4 • OU SELLER DOES NOT PROVIDE: Building Permit, ground preparation,electrical POOL TOTAL 35108 5• (�(�_ work, or water to fill pools. INSTALLATION AGREEMENT \1 SLSC] . C-)C�) _ , Al o4E st V TOTAL INSTALLED PRICE q-1 \S S• G 0 ?j 0 C) OC) c �1.u,s i o�E .3'cool 0o DEPOSIT PAID WITH AGREEMENT 500• �� �� 1 o00 . o0 DEPOSIT REQUIRED TO ORDER POOL � \"AGREEMENT AMOUNT DUE ON DELIVERY OF MATERIALS g,O OC) FINAL BALANCE ON COMPLETION (0 (7�S,00 BuyerX Date 5/t 3 20 DATE REQUESTED Received - By X _' /- �---�...'�"._._-- Date ` /3 ;-c' L The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 t Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name (Business/Organization/Individual): �r�5 r� Cell AD* 4,4&Ae-- A29l S Address: M=mom' W cA r Arr,* 0/00,,­0 City/State/Zip: Phone#: !t/3 — 53UC) Are you an employer?Check thea opriate box: Type of project(required): l.M<-'m a employer with employees(full and/or part-time).* 7. []New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5. I am aeneral contractor and I have hired the sub-contractors listed on the attached sheet. g 13.�Roof repairs These sub-contractors have employees and have workers'comp.insurance.= A / 6.❑We are a corporation and its officers have exercised their right of exemption per MGL C. 14.( Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I 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 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 for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: l Expiration Date: Job Site Address:I�D-1 C�hd�1 La\, � •1 City/State/Zip: O��(y.� 0� � 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 certiify un F pains and penalties of er' that the information provided above is true and correct! Signaturey Date: _ Phone#: Official use only. Do not write in this area, to be completed by City or town officia/ 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#: City of Northampton >•, Massachusetts �y Y DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 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.G.L. Chapter 142A requires that the"reconstruction,alteration, renovation, repair, modemization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are 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:_ o f Est. Cost: �f, Ova. CO Address of Work: 16-0 CCLVJ i n�,� r10P't�-� ►�-� dy� - Date of Permit Application: 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 owner-occupied 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: I hereby apply for a building permit as the agent of the owner: 1� --�3 <Si I I(-V� J I(D 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: 0 Date Owner Name and Signature