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35-289 (17) 9 SYLVAN LN BP-2020-1195 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:35-289 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Categoa: Inarround Pool BUILDING PERMIT Permit# BP-2020-1195 Proiect# JS-2020-002003 Est.Cost:$19570.00 Fee: $105.00 PERMISSION IS HEREBY GRANTED TO. Const.Class: Contractor., License: Use Group: JULIANO'S POOLS 139826 Lot Size(sq. ft.): 32713.56 Owner: FRIEDMAN PERRY Zoning: Applicant. JULIANO'S POOLS AT. 9 SYLVAN LN Applicant Address: Phone: /rrsrrr nnc e: 321 TALCOTTVILLE RD (860) 870-1085 VERNONCT06066 ISSUED ON:6/5/2020 0:00.00 TO PERFORM THE FOLLOWING WORK.-1 8X36 INGROUND POOL *note - pool barriers must be in place before pool is filled with water* 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 Occupancy Signature: FeeTvpe: Date Paid: Amount: Building 6/5/2020 0:00:00 $105.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2020-1195 APPLICANT/CONTACT PERSON JULIANO'S POOLS ADDRESS/PHONE 321 TALCOTTVILLE RD VERNON (860)870-1085 PROPERTY LOCATION 9 SYLVAN LN MAP 35 PARCEL 289 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out Fee Paid Typeof Construction: 18X36 INGROUND POOL New Construction Non Structural interior renovations Addition to Existing = POOL 15AARMWIAA9r Accesso Structure Building Plans Included: wr 10 t ACk PQ 2,C Pool— Owner/ ob`.Owner/Statement or License 139826 S IF(LLAZ WIT t j W ATE 6-- 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFQRMATION 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* t 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 -q 20 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. M Z 4 File No. DCL. �"6fZONING PERMITAPPLICATION (§10.2) ase type or print all information and return this form to the Building 'tor's Office with the X30filingfee (check or money order)payable to the City of Northampton ji Applicant: (awl►f I i � -P y a ss-r ,� I, Q 's Pct i S, LLC ? �I _Tou C l—t-y ' t l P--'A _ Telephone:�'CQ U- 513— 2. Owner of Property: t?a f-t a, r-'- td VVIOLX1 Address: 9 - w LV e`.n �—an- Telephone: � 3- 3 -1 L4 - 2-9 1 g 3. Status of Applicant: Owner Contract Purchaser Lessee Other (explain) 4. Job Location: 'I S u L a Y)-e— Parcel Id: Zoning Map# Parcel# District(s): In Elm Street District In Central Business District (TO BE FILLED IN BY THE BUILDING DEPARTMENT) 5. Existing Use of Structure/Property: 6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary): C 0 hs tri (--t i o C 1 8 X 3( o lam-e c-tc� 17, 1 I 7. Attached Plans: Sketch Plan _ Site Plan _ Engineered/Surveyed Plans _ 8. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW �Q YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW -O YES IF YES: enter Book Page and/or Document# 9.Does the site contain a brook, body of water or wetlands? NO )2� _ DONT KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , date issued: (Form Continues On Other Side) W:\Documents\FORMS\original\Building-Inspector\Zoning-Permit-Application-passive.doc 8/4/2004 10. Do any signs exist on the property? YES __ NO IF YES, describe size, type and location: Are there any proposed changes to or additions of signs intended for the property? YES NO_—,& _ IF YES, describe size, type and location: 11. Wilt the construction activity disturb (clearing, grading, excavation, or fitting) over 1 acre or is it part of a common plan of development that wit( disturb over 1 acre? YES NO _'L IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 12. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION This column reserved for use by the Building Department EXISTING PROPOSED REQUIRED BY ZONING Lot Size • �5acrts Frontage Setbacks Front Side L: R: L: R: L: R: Rear Building Height Building Square Footage %Open Space: (tot area minus building tt paved parking #of Parking Spaces #of Loading Docks Fill: (volume Et location) 13. Certification: I hereby certify that the information contained herein is true and accurate to the best of my knowledge. Date: 2O 2-U Applicant's Signature &Zua NOTE:Issuance of a zoning permit does not relieve an applicant's burden to comply with all zoning requirements and obtain all required permits from the Board of Health,Conservation Commission, Historic and Architectural Boards,Department of Public Works and other applicable permit granting authorities. W:\Documents\FORMSbriginal\Building-Inspector\Zoning-Permit-Application-passive.doc 8/4/2004 Department use only j City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability I( Room 100 Water/Well Availability, Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Proyerty Address: This section to be completed by office 0-n f o-��� Map >t Lot oI a [ Unit T- 1_ Zone Overlay District FI oY-e1 n C,-e. , (�.� o l b CaZ Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: V �-E4 q .S�l v�n La YA q-- Name(Print) Current,Mailing hddress: � TI Telephdne Signa 2.2 Authorized Agent: TL I c,ott v l I l Z Name(Print) OO 1 J Current Mailing Address: V e 1-n on i CT0(9!V .. &4'1 I �a () - 5 -13 - 119 l Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building q o 2 (a)Building Permit Fee 2. Electrical 1' (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) (66 5.Fire Protection p, 6. Total=(1 +2+3+4+5) ( IBJ-70 . o Check Number This Section For Official Use Only Building Permit Number: IIsssued: Signature: Building Commissioner/Inspector of Buildings Date 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 Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height N I Bldg. Square Footage w f P, % Open Space Footage 1 % (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 O DONT KNOW ® YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW ® YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained 0 , Date Issued: C. Do any signs exist on the property? YESO 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 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 Y 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 [0] Decks [Q Siding[Q] Other[I:J Brief Descrition of-Proposed Work: X Alteration of existing bedroom Yes No Adding new bedroom Yes — No Attached Narrative Renovating unfinished basement *es _ No Plans Attached Roll -Sheet 6a.ff 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 )O No. Is construction within 100 yr. floodplain Yes_ (. to j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? T Yes No. I. Septic Tank___)C City Sewer Private well)DTTCity water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, P-e.'�_N7_ , r\ ,as Owner of the subject property \ i hereby authorize �) ` ,� a X1s V n n i S L uC til c to act on my behalf,in all matte relative to work authorized by this building p rmit application. 11 .-' O2O Signature of er Date I, 1)D n i 2 [ I c_ Le v p_ r , t,ki, G��n`S p o o IS ,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. J )( ,o t-c L-P_ V Azseu r Pnnt Name 512-0 Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 9.Registered Home Improvement Contractor. Not Applicable ❑ fR ti 0..tn Poo As LL-(- H I e - U to 12- 2-7 k Company Name Registration Number 3>2— i -TpAcD tfv , ( w 11130 )2o2-v AddressExpiration Date \�P f no n CT0 (a 0 LOQ O Telephone(t(P U- � -70 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.......1 No...... ❑ ;iT j.. 106 h k7r 1 21 Snwauf i� ? ti7 ,Rti �. �gm; � t ' 4•". 4?11 SnV^W .r n Nlr '4 Vey. Standardized ("Level 3") assessors' tax parcels as a tiled map service from MassGIS, hosted at ArcGIS Online � �1 MassGlS, Esri Canada, Esri, MERE, Garman, IIVCR.EMENT 6', USGS, EPA, i City of Northampton 212 Main Street, Northampton, MA 01060 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: The debris will be transported by: y1 ► o's 1 �� �kS i� u 1 i The debris will be received by: Building permit number: Name of Permit Applicant >' W C\e . LC kI,sce�)c' -5 12012.02-0 &UA T /-- Date Signature of Permit Applicant City of Northampton / • !" Massachusetts G DEPAR7MMT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, NA 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, modernization, 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: C 0 C A -e 1cSt. Cost: / 570 W� � bpi Address of Work: Date of Permit Application: 12.U 2 y I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): _Job under$1,000.00 Owner obtaining own permit(explain): Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: � I2UI2C> � p �(`i , I � C�YZCU H (C • Wo1z1 � F Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature 1 ism, ! #y 1 Lit E th II't?l.r'.f. 9i-LBJHI*I V E on f:J,t n :0F R. K NOM IAN)U #t.A1i t � � ►.+' : ;?(' �'a. i. r`a f.}r. ME 13htJKV.00e,11--BO( IW ON 1% t'I O 1 • l=. a i't_i)• «.1 p,, q.i)ISi±)-.()K Ybl.l R IR i'. 110*';w. VJtt4K0A,C'W(.41 /it:l:r M-" ?MO Hi.fx"+?!Y . :: Af. '*111 CNS EVE MAT !ra IA)My 1 KWO Ali V f .-:iccl MM!, �f+�'t!G CJr)( "t!l i �r :.:,ti;� if.j(j)�:lsl;}• ,i. 11 1p r.ti3:t,i5 "IS' + AxA 110" -QM ilk WO, ,1t4agj.UAV,-A Vk, _.. 4 > , _t. .'r:' -.. C,�t.'t�S1ul; 'S►(i`2�1. '.•� �.`;}4• ;�.fi y"ynf•:..*.i)�40$Cii;•.. i.q .. ... :?^.., �a'. .. r`"; 9%j 'n .'ok t,k v fr i n, o-1 rkAr i :', � , ., ., CJ. 'i� a.? ,�3 10r�'e. i,6U{3.: !Js�. t: _ ;t.,•.; 1�,-•t irlF,r f?.,1P_Gl11,'j: (•ti, '' S':y1<! U'.. C:!. �7111!ji` 1" ire" { ;,i.eF %}4 % ��. ? I= 5F3 r• ljJ �f.i,' , r l)` m; sli t%p�a.!':9G1k fa jj wit Vbhilf,lp ., MY wN, • - c,r e ;ter t' ; , City of Northampton ,,` •. Massachusetts '<< i " ; DEPARTMENT OF BUILDING INSPECTIONS ' 212 Main Street • Municipal Building yeti rs� "ry Northampton, MA 01060 Massachusetts Residential Building Code Section 110.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.R5.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s) for hire to do such work, then such homeowner shall act as supervisor. Such homeowner shall submit to the Building Oficial, 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 ;,�•� Massachusetts F. G f DEPARTMENT OF BUILDING INSPECTIONS 7. z 212 Main Street •Municipal Building 'd Northampton, NA 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: q l \ay-\ LC,Lv-\-2 (Please print house number and street name) Is to be disposed of at: 0\k o' d s PO4vs 32i (Please print na and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: USL� RnkI �i►-NO% (Company Nameand Address) &UA 5!w 1202,b 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 of Massachusetts Department of IndustrialAccidents I Congress Street,Suite 100 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 Lesibly Name (Business/OrganizationMdividual): l 1 s cc{0� Address: 32- l TaA r 0-tN k 1\e- 1-e1 . City/State/Zip: �J-Q Cao Y) , Cr OW () OcW Phone#: WO - 8-]O - I 0(��S Are you an employer?Check the appropriate box: Type Of project(required): 1.81 am a employer with 12 U 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. F]Remodeling any capacity.[No workers'comp.insurance required.] 9. 3.a I am a homeowner doing all work myself.[No workers'comp. 1 insurance required.]r El Demolition 10[:]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.E]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.1:1 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[�ther� 152,§1(4),and we have no employees.[No workers'comp.insurance required.] POO I "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 1 t Homeowners who submit this affidavit indicating they are 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 and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I ane an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. n Insurance Company Name: AMA- Ws u �-O ra c e- co . Policy#or Self-ins.Lic.#: 0 -7 5 2.9 2%irdq tioon Date: -7 I Z.0-,-)-6 Job Site Address: S �1 V a.n Lan e. I-I U re n L it State/Zip: a r-e oc Q , M/4 `/4 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. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature ,l Date: 5 ,12—Q 121J Zn Phone#• 1 1 9 0 Official use only. Do not write in this area,to be completed by city or town offwiaL 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant 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 a joint 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 appurtenant thereto 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 license 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 any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance 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-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department 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 any 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. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at 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 permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)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 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia bna noile"i'll-lolfil I t •IT. ei t j n jj -11to_ "!(I; !.11vw 1, iorui i fi*.i.: jd: 'li VVIO lTtiWi Vr� to*l i 1W) i,od qrlAl-"Arb i .1a odt bluiloi,i.v lko !mnv 'Plner yo,�, rl 16, �oil[V .Wi­ ;,ii I- . -liNilim! 0 t) ­%Jou,; pll�"j"Ja or finrl.,#q t.,soal)lii a I IY "j T.M 11i'll; XI 111; `,ORCO!p'J lltl'illbO-if 1110 AMl INIP iq- A i;Wll i dV C, Ifol 5!", OAi+ js_'OI f vA f _X,I, ;it 0jlP ;;i l(T tilt! :71 Rd Wrp ifi: I"A �q A r rt Ok Letter Of Authorization I,as owner of subject property,hereby authorize anyJuliano's Pools Inc.personnel,to act on my behalf to pull an in-ground swimming pool building permit(and including any/all matters relevant to work . authorized by this building permit),using as necessary his/her/their home improvement contractor license,plumbing and piping limited contractor license, electrical contractor license and swimming pool builder in-ground license. Customer Name: P— '2- 16 D MA N Customer Phone:_ Address:_ S Y L V A N L-A N c r-Lo 2L N LC, l� - 01041.1 Thank you for your consideration in this matter. Sincerely, (signature) Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, mas,19Nhusetts 02118 mprovemeYlC Home Ir Registration Type: Individual Registration: 139826 BRIAN JULIANO " D/B/A JULIANOS POOLS tea. +if* V"w< Expiration: 08/26/2021 �=�- ,mss==. ,F;._� ��z 321 TALCOTTVILLE RD. 'q� r �- VERNON,CT 06066 :a ,5 �- ra �,r SCA 1 is 20M•05/17 Update Address and Return Card. ✓fie t�i�ninoitu�ea�/�a�✓�¢���c�u�edGi Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TY, Individual before the expiration date. If found return to: Re stratlotl_, Expiration Office of Consumer Affairs and Business Regulation 82 — 08/26/2021 1000 Washington Street -Suite 710 BRIAN JULIA14t� x Boston,MA 02118 BRIAN R.JULIANp� 321 TALCOTTVILL 1y «fC.('�GIC VERNON,CT 06066 Undersecretary ®$ art WithOut S9gnature CERTT l(' CA Il E OF L�I/�1L��LL,d U 0 ���SIJU'�!i` NCE DATE /YYYY) 1//3/2023/2020 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 TH E 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. If 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 NAME: Andrea Hills The Jarrett Agency PHONE 8607454222 AIC No Extl: (A/C,No): 657 Enfield Street andreah kovera e ou com ADDRESS: Grp g br P INSURER(S)AFFORDING COVERAGE NAIC# Enfield CT 06082 INSURER A: PHILADELPHIA IND INS CO 18058 INSURED INSURER B: AIM INS CO 18929 Juliano's Pools,LLC INSURER C: EVANSTON INS CO 35378 321 Talcottville Rd INSURER D: INSURER E: Vernon CT 06066 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. POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD (MMIDDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ®OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A PHPKI925369 01/01/2020 01/01/2021 PERSONAL a ADV INJURY $ 1,000,000 MGEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ❑PRO- POLICY LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY (Ea accident) $ 1,000,000 ANY AUTO BODILY INJURY(Per person) S A OWNED SCHEDULED AUTOS ONLY AUTOS PHPK19253690 01/01/2020 01/01/2021 BODILY INJURY(Per accident) S -/ HIRED NON-OWNED di AUTOS ONLY Ix AUTOS ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 3,000,000 A EXCESS LIAB CLAIMS-MADE PHU13660514 01/01/2020 01/01/2021 AGGREGATE $ 3,000,000 DED I I RETENTION$ $ ORKERS COMPENSATION PERU ND EMPLOYERS'LIABILITY YIN STATUTE ER B OFFICER/MEMBANY OR/EXCLUDED?ECUTIVE El In NH) N/A E.L.EACH ACCIDENT $ 1,000,000 WMZ-800-8007529-2019A 07/13/2019 07/13/2020 If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 PER OCCURRENCE 2,000,000 C EXCESS LIABILITY MKLVIEUE100452 01/01/2020 01/01/2021 AGGREGATE 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) as evidence of insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Juliano Pools,LLC ACCORDANCE WITH THE POLICY PROVISIONS. 321 Talcottville Road AUTHORIZED REPRESENTATIVE A.,.drea HAs Vemon,CT,06066 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD OWNERS MANUAL Do not return thi,product to ba n"Irrad io flee vetWier from whom th�Iwodurt ww, porchesed, ALL REPAIRS HOW TO BE SEW T TO 10MMM ft-SIGHS, For Service Call Driven Designs, Inc, (61 6) 794-9977 Between 8.00 AM and 5,00 PM F-,q:T, DRIVEN DESIGNS, 114C. 1136 S. Bridge St Belding, Ml 48809 Phone 616.794.9977 Fax 616.794.9987 www,poolpatrol.corn f w TABLE OF CONTENTS P1A-2,9&PA-3o.......................»..............................................................I.............................6 Genenal........................ ..................................................................................5 rir x Contents...................................................................................................6 PA-30 curtlents............................................................................................6 PoolPetrol Models..........................................................................................6 PA-20..........................................................................................................6 PA-30.........................................................................................1.........I......6 PA-26...............................................................................................-A.......B INSTALLING OR CHANGING THE BATTERY.....................................................................Y SENSI T'IVITY ADJUST..........................................................................................................a ALARMRESET, ................................................................................I..................... .9 ALARMPLACr--V ENT........................................................................................................16 SoftSided Pools...........................................................................................12 RECEIVER.........-.-...........................................................................................................13 setup.............................................................................................................13 TransmissionModes......................................................................................13 ModsChange................................................................................................13 SNmode.......................................................................................................14 IDmode...................... ................................................................................14 LeamMode..................................................................................................14 ErasingMemory............................................................................................14 Resettingthe Reoeiver..................................................................................16 RECEIVER PLACEMENT..................... . .............................................................................16 SYSTEM TESTING AND OPERATION...............................................................................16 TESTINGTHE ALARM..................................................................................16 LOWBATTERY...................................<.........................................................18 FALSEALARMS............................................................................................16 POOLCOVERS.. .................................................................................................17 STORINGYOUR ALARAN...................................................................................................17 CONNECTING TO A HOME SECURITY SYSTEM............................................................17 ClosedLoop..................................................................................................18 OpenLoop.....................................................................................................18 TROUBLESHOOTING.. .................................................................................................19 (god Pub Imlbod warranty. .............................................................................................21 Page Z - - -- page 3 FCC ID PA 25 +& PA40 Congratulations on the purchase of the finest pool alarm in the rnarlcei. THIS DEVICE COMi'LIES WITH PART 15 OF THE PCC RULES. The alarm is manufactured In the USA with the highest quality and we OPERATION IS SUBJECT TO THE FOLLOWING TWO CONDITIONS: stands behind every Pool Patrol sold. The alarm is designed with (i)THIS DEVICE MAY NOT CAUSE HARMFUL INTERFERENCE,AND plastics engineered to resist cracking and Lading over time. The (3) THIS DEVICE MUST ACCEPT ANY INTERFERENCE RECEIVED, electronics are microprocessor controlled using the latest In transmitter INCLUDING INTERFERENCE THAT MAY CAUSE UNDESIRED and receiver technology. During assembly each alarm goes through OPERATION.. several rounds of inspection and testing to ensure years of trouble free ;-.eryice, General INFORMATION TO USER. This manual is written tot the PA-25, and 30. The POOL PATROL Alarm is intended to be an additional layer of NOTE- THE MANUFACTURER IS NOT RESPONSIBLE FOR ANY security to protect your loved ones. The POOL PATROL Alarm is not RADIO OR TV INTERFERENCE CAUSED BY UNAUTHORIZED intended as a life saving device. It is not intended to replace any other MODIFICATIONS TO THIS EQUIPMENT, SUCH ODIFICATIONS safety considerations, such as adult supervision, lifeguards, fences, (COULD VOID THE USER'S AUTHORITY TO OPERATE THE gates, pool covers, locks, etc. The POOL PATROL Alarm may not detect QUIPMENT. from gradual entry. it is important to spend sufficient time in becoming familiar with the operation of your POOL PATROL Alarms and to properly test the unit so that It adequately covers all areas of the pool for the person(s) or pet(s) you wish to protect. • Do not use this product prior to reading the instructions. • Do not allow the pool alarm to float free. • Do not drop, submerge, mistreat, or place unit upside down in the pool. i • Do not use when pool sweeps are in use or while cleaning. Do not place In pool near filter return area. • Do not use with other objects In pool, such as ioys, dispensers, chairs,etc. Do not alter or attempt to repair the unit yourself. • Do not leave out overnight until you have learned how to operate the alarm. The PA-25 and PA-30 POOL PATROL Alarms meet the requirements of ASTM* Standard F220"8**, *American Society for Testing and ---- Page 20 ------__.-- - --- _-- ---- -- ----- -- Pages — - To connect to a home security systern there is a connector at the bottom INSTFLING OR CHANGIN s THE BATTERY of the receiver with three inputs: (See Figure 11) The pool alarm requires a 9V alkaline battery. One 9V alkaline battery will last for one year under normal use. The battery is in a compartment Fi urell Security' ender the floata�ifon base. You will need a Philips scmw driver to remove g Connections the battery cover. 1) `burn the alarm upside down. Note the black floatation base and time words "BOTTOM" and the word "SENSITIVITY" with an arrow to "INCREASE" or "DECREASE" the sensitivity. To remove the float, turn the black flotation base in a counter-clockwise direction or in the "DECREASE" NC Normally° direction, until the base is �O - Normally Closed Figure 1 Battery Cover loose from the upper blue Open housing. ivigure 1 is a picture cit the battery cover with the float removed. C..Common 2) Once the floatation base is The home security system will connect to two of the three terminals. off locate the battery cover j Check the security system documentation to determine if the system is (Figure 1). Remove the ar, "open loop"or a"clued loop"system. These inputs are connected to two screws and lift off the a relay and only provide an open or closed contac L battery cover and gasket exposing the Oki bury Closed Loop clip< If the security system is closed loon, jho canrjections are wade io the "C," and "hir " terminals. When the receiver alarm8 the relay will open ;i snap a 9-volt alk-aline and trigger the home security system= battery on to the battery Open hoop clip (figure 2) and For an open loop system, connectlon8 are made to the "C" and "NO" carefully insert the 9y; rorminals. When the raceiver alarms the relay will close and trigger the battery and clip into the battery corrspartrnersi< I�igwre 2 Battery Clip home sec:urit�i system. IMJ! T Use only a 9V alkaline battery. Be careful when installing or removing the battery as the battery clip can break. page'to Page - - - - -w-m TESTING THE ALARM Bafore the testing, be sure the sensitivity of the pool alarm is at the most . sensitivity position (ref: SENSITIVITY ADJUST). Reset the alarm by turning it upside down and place it carefully in the pool at the location Increase previously determined in ALARM PLACEMENT, Move to an area of the pool that is farthest from the alarm. Carefully clip the bucket in the water and fill it. Lift:and hold the bucket approximately 6"above the water and drop It into the pool. Decrease The alarm should sound with the wave crested by the bucket. The rec*iver should also sound immediately after the alarm in the pool was trlggered� Reset both alarms. Test at other locations in the pool to make sure your alarm works at all locations. Between tests wait 10 minutes to allow waves to sattle- IMPORTANT _ Figure 3 Sensitivity Adj If any adjustments are made to the sensitivity,adjust the float a %turn at a time. Track the total amount of turns that you make and writs It down. This will save you time later when you need The "Sensitivity Marks" to change the(battery or set-up for next season. (Figure 4) can be used as a general indicator for the -sensitivity position, LOIN BATTERY Your pool alarm is equipped with a low battery indicator. If your 9-volt Should the sensitivity alkaline battery drops below 6V It will sound a "chirp" once every 60 need to be adjusted start seconds. The receiver will also chirp once every 60 seconds to indicate making adjustments by the alarm In the pool has a low battery. turning the float only a 1/4 tum at a time. Test the Replace the battery in the pool alarm fdilowing INSTiAL,,L1.NG 4R alarm after each CHANGING THE BATTERY on page `a•, next reset the remote receiver adjustment (see testing following the Resetting the Receiver on page 13. page 3)� We do not recommend turning the FALSE ALARMS float out more than three FIguro 4 Sensitivity Marks You may find that one setting is ideal for regular use when the surface full turns, water is placid, however, it may cause false alarms if there are winds : raatar than 12 Mehl or during a storm. To avoid false alarms, you may Y odde to temporarily deemase the ssnsitivity You should then retest your alarm at the neve netting to verify that it will sense the child or pat ALARM RESET you wish to protect at all areas of the pool. To reset the alarm at any time pick up the alarm and turn it upside; down '1800 angle) for 6 seconds. This action will reset the processor and ------ ---.- -- - -- Page 16 --- ---- ----- -- - - ----- Page 9 ---- the movie button clown while turning on the receiver, once the receiver is It your pool is larger than 20 x 40 ft. we recornmand using more than one turned on, release the mode button. The unit has now changed modes. pool alarm. Refer to Figure 6 for placement of more than one alarm. BN mode In this mode the receiver will accept any Pool P.9tRsi irah,m!V.au�, t �.� X 10 Mode ,, �..".-�- aC���,, � s. In this mode the receiver will only accept the transmissions from only � X those ID codes the receiver has learned it lochs out all other trans3mitters -. �_ i ( a Mode 1. Button x Learn Mode With the receiver in ID mode, � X pushing and releasing the k' mode button once will put the x receiver In loam mode musing X the LED on the front of the receiver to tum green. Learn L _f mode will timeout after 18 Figure 6 Recommended placement for pools larger than 20 x 40 ft.. seconds and the receiver will go back to normal operation Determine where inthe pool the alarm will be placed. Remove ti* causing the LED will go back string and clips included with the alarm. to red. Once in learn mode the Measuring from the center of the alarm, place the alarm approximately receiver is waiting for the ID 12"to 18" inches from the side of the pool. From this position determine code from a transmitter. where the tie-down locations will be. Cut the string to length enc' =easy "rigger the transmitter and approximstel 2" of slack in the string for the alarm to function and i.3e send the serial number and ID Figure 10 Mode Button removed easily. Tie down number to the receiver. To locations should be as clos€s to trigger the transmitter connect the ring and post with a paper clip or piece the water level as possible for of wire, the best result. The receiver will take the iD number and store it in memory. Up to 8 Note. To keep the nylon string transmitters can be learned by each receiver If the receiver accepts the from unraveling be a knot; hi the ID code from the transmitter the green LED will turn off and on and then 09", end or uge heat to melf the turn red and blink rapidly. ,. strands together. Erasing Memory Tie one end of each string iso Place the receiver in ID mode. Holding the modes button in for 10 each tab on the float (Figure 7). seconds will erase the receiver memory. All of the transmitter ID Tie the ether and of the stings to numbers stored in memory wMli be cleared. Once the mode button is each tie down location of the pressed the LED will tum green for 10 seconds When the LED turns off Figure 7 bloat Tab pool, Da not plan the alvAesr, the memory is erased. ,After releasing the mode button the LED will any eIoserr than one tort frori the- side of your pool Leave -- Page 14 Page 11 - - - ---- _ _ _ 1# ( i EtEl � 1. ;\1 IN 1c1 bx, 1 se -c-ice.n1 a.V-NtA. to A 4115�yl AM.W,-ill a D&D Technologies Installation syallaon Instructs t5 Wv If'n."tt(WoA50r(rm!*4 Arfacedimientas tis'Mstaiacl& Round-Pod ktla 'Kit IttstructLttm GMIW,Ma(xrat atctr rfrtvitMs tc:ft't&!t niaksl;t<actjusfrtFotR for chrfact aNgtaFfetii.It is tarn tttotetbr`slokvpar's s Ospatsii my to rr wft the WO pfttpFtrftr laftes at all tkift.Seo"is 11&12. Pk'�t14t6tt;kfa{trt�.aich nkerrr ct;rtif�f y iu)rfd�tfaf Odra rata+{arfecfa A'h��foacYtirt, �s resPClns�f6iikittr rtol rutsAtdbr vp eWiu asagrxarre dr ruler v11A*S-b fie k ptfffftfa Ctw mmdh me4e s,5 i i•6b momanto. turf Ams 3 f v fid. 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Off AINW.;PIME iWOE-ef%APR Nwrl"w ' We S 1 li ik l�.�ws AtiSTRAUA;LifI4 6,4,r AQURtia t#',FrIMClts lot M NSW 2096 - Mi m1mv#1 dkW Orb de fa prsctm fes r ro*aa des propfhrf3 s ecours; USA;7731 tF endroind f}nw,tfurOrtgtotr titfxk CA 9264T •110040mv PS PWkfr w) FtJRaP1=: Rt�asstry#4'i r 353.1 q►lt UtreclFt.'ftte N�troflotldS• "SAW(15 Peart M Ftxvcc) ( •C,anha ssltipoisemt Fence reference Guide Pool barrier must be at least 48"above Maximum clearance of 2"above grade, Gates must be self closing/self latching grade measured on side of barrier away measured from side of barrier away from the with release mechanism 54"above grade. from fence 13001 Gate must swing away from pool. i If release is less than 5411 then release must Por Solid Barrier—Nn indentations or per pools using house as part of harrier be on pool side of fence at least 3"below protrusions should be present other than if door opens to pool area it n-tust bo top of trate and gate have an opening less normal mason joints equipped with door alarm on inside wall than YV within,18"of gate at least 54" from floor For Barrier made of horizontal and vertical Vor harrier made of horizontal and vertical Vor Chairs Unk Fence Mesh size cannot members—If less than 45"between rnerabers—If more than 45"between exceed 1%"unless slats are fastened at horizontal members,vertical menr►bers must horizontal rYmembers,vertical members must ton or bottom of fence and reduce not exceed 13/4",decorative cutouts must not exceed 4",decorative cutouts must not opening to no more than 1 V/" not exceed 1 N",horizontal members must exceed 1%",horizontal members may be on be on pool side of fence side of fence away from pmol i i i i tSVifG%A4$C0C Rev U HfflffliMU CERTIFICATION OF COMPLIANCE Contains: WG'048E, WG1048EBLK, WG1048EGR, oi- WG'048EDGR Description: 8" Round Suction Outlet Cove Ratings: Ftaor: gall: - --r-�..-Open Area-.-- ;�� Certified to Corn fyWth��1404 of1the Virginia Graeae Barer Act (V615) Poor 6 Spy a Safety Act codified at 16 C part 1450. initial Certification may 2ov1. Manufactured: After September 1a, 2oo9, by a Division of Hayward industries, Inc. at 14-A, 2,1402,8 Block K4- A, Export Processin Zone Wuxi Deur District Ilangsu Province PRC 21.07-8, Chi Ila; or at One Hayward industrial Drive,tlernmons, NC 27012. Certified by Harytntard Parol Products, 62o Division Street, Elizabeth, iii o72o7, Phone 90$-x55`7995 Contact at www.havwardnet.com Record Custodian is Customer Service at'aCtoeUt haY Hayward Pool Products P.O. Box Stop Clemmons, NC 27012-5100, Phone: 336.71249900 Bate of Mfr.The Lot Number shown on the product label contains the Year&Month of rnanufacture. The first slumber represents the year(ex i= 2oii) and the second character the month (Alan, B=Fein, H=Aug, i is skipped,)-Sep, etc) Tested to: ANSI/APSP 16 (ANSI/ASME 112.19.8.2007 (addendum gb-2009)) Per Section 1404 of the Virginia Graeme BakerAct(VGB) Pool&Spa Safety Act.Tested by NSF International,789 Dixboro R oad Ann Arbor, Nil 4811 , Phone 4.769-8oso in April toss. Certificate at- U,��[=21600&St�rld 1JJgQ$ Date of lostallatiorl:—.�... _ - ---..-=_ Suction outlet components have a finite life, the caver'g.rate should he inspected rrequerrtl�' alit! replaced at least everynW5,or if fry+incl to he damaged hrtrke��, cracite�; r? issin or r►ot sec�trei;r attached. Haywarr Pool Products acknowledges that is is a federal crime to knowingly arrd willirr ty make trat�rlalfy false, fictitious, or fraudulent statements, reDreserftations, or orrNsions on this G' ,zPAQIFK%KTW EGN hAutltgTir`*14OLCS r SED 00 FOLLOWING SERIES' W1"IMAYM2 SP1830AVPAK2 4b flfFfrIOUAVI'AKl SP104A1I'M 7;s��t., wG1044AVPAK2 S[100AVP1�K2 ppo WGi 051 AV PAKI 5P 105t AV PAK2 'jiK.11(M i AITI Lt O kllGIMAVPAK2 01652AMIC2 _fix EkW'..g1QtP.0 WGIOSSAVPAKz SPIOUAVPAK2 t WGIO54AVPAK2 Si'1084AVPAK2 WG1153AVPAlt2 SP1153AVI'AK2 WG1154AVtAK2 SPI154AVIAK2 I A Wsming- Sudlon Entrapment hazard. Suction In suction outlets andjor suction outlet covers which are installed its a small area and/or below the surrounding surface can cause severe htluty or death due to body entrapment hazard. To reduce the risk of body entrapment,installation of the field fabricated sumps must bo such that the top of tho mounted water is a rhtirtlmum ar l t/2"above the finished pool surface over an area targer than 4o"an a diagonat. _._ l r . . . COMMO-Vk% r-JL TH OF 41 y � _ EXEC UTWE OFFICE OF _+ f DEPAR7WMNT OF FJW ONE NVITE i REST, SOSTC ARGEC FAU:: l ELL V*M Governor SUBSURFACE S YA E DISPOSALS PART A Property Addra:4: Mss Addrou of Ower: Dote of Ins pvc on f`'� /0-0 orr� Opprrovvd s ystorn inspe art PJTZU t to soon 15.340 w Cy H arms: Affordable. Hoyte and Septic Inspections Inc. I oi-L"g Ar L,:4 . 1 Il fit. TO epho` Hal yokearia.. 01040 413 45 32-48600 CERTIFICATION S 1"A TEMENT certify pFerSon&Ay inspecial t4-t 94Pwa9e dispes*' s jatem at this at a-ld cormpl ete s: 0 - the tinne of ins peCtio n, The inspection v% as performed b e s rnaimenence of vn sits wage d-LIp0,53f sYslems. The syslem: Fssses cor-drt+o hall y Posses Beads Fwiher EVA)US11-0M BY tfle Lo-csf Approwing Awth Fara s Sjj6S U ptFA CE SEWAGE OtSPOS AIL S S TEIk PART A A nor: Qt*k 0 of Inspeclim: --L 1 ECTION SUMMARY: or D: SYSTIEM PASS ES I have not found any irtforM860ft w iclh indicalas Ihat *ny of tha failute cc rritefia not evaluated ave indicated balow * MMEN TS. SySTW CONN ONALL PASSE-S4& One of more system components as described in the "Conditional Po s s' r c.ornpletion of the replacement of repair, as approved by the 13oard of Has icate yes, no. or not dererrnined (Y. N. or IND). Describe basis of determination The septic tank is metal. unless the O w nef or operator has prov Compliance (attached) Indic sting that the tank was installed vw h the septic tank , vvh*ther or riot metal.. its cracked, structur0y u failure is imminent. The sys ' ++rill pass inspection H the exist approved bar the Board aattl�. Sew backup or breakout or high static �+wrater level observed cr ue to a broken, se 4d or uneven distribvtion box, The sys estthl. k.,•.!Lm,� r%;w-talci Arlt rpntae&d SUBSURFACE SEWAGE DISPOSAL SYSTEM IF PART A ty A { URTKER EVALUATION 1S REQUIRED BY THE BOARD OF HEALTH; _ Conditions exist which require further evaluation by the Board Of Heatth in o, public health,, safety and the envitonrne.nt. SYSTEM WILL PASS VN L�MANNER RD OF HEALTH DE rmMIN ES 1N A1C COR IS NOT N TI ON IN AWHICH WILL PROTECT THE PUBLIC I Cess$�001 iDr privy is within SO feet of surface w*tsr essp��4 r Privy i5 w+xhin ,5Q feet of a bordering vegetated wetla ti SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (ANO PUBLIC t ATI FUNCTIONING 1N A mANNER TKAT PROTECTS THE PUBLIC HEALTH[ AN The systerr+ has a septic tank a oil-'a sorption system [SAS) a Iriblrtery to a surface eupply. The system has optic tank and sail absorptiGn :ystam and the a c.ntir. tank and soil absorption system and t e USSURFACE SEWAGE DtSPOSAL ST tr M tM mom" PAIRI A T11CATION + ' y r � - s T FAtl.S indir-ste either "Yes" or " .. to iosch of th* 10110winglure ca�ditiOcl3 exist as d I hs e determined that On* or Mo rs o f the f��o w to� t� should bo contacted t0 t clet errr�ri wti om Is identified below, The Boord of Health NO Backup cpf sigWage tato facility or system oomponem date to en ovar o Discharge o ponding onding of aiftuent do the surface *f the ground or surfs cesspool. Static liquid levet in the distribution box above Qutlet invert die to en Liquid e th in cesSP001 is Mess than 6" below invert or available v b!u Requited PumP inn more than4 rm the tact Ye er ' due to CID Number of timts RumPed Any portion of #il Absorption ystem� cessP001 *t p�r'vy is "10 Any P0 n of a cesspool or privyis within 100 Ieet of s surface W y portion of a cesspool of Privy is within a Zone I of a public Wal1 ool or Vfivy is within 5o feet of a private +a+ Any portion a# acess P Any portion of s +cesspocR Of priory 's less-then 100 feet but greater T ,�r�catabEe ,r�at�s �ua�it� ar�a�Ysis_ if the well hes been analyzedto tiRFA SEWAGE C)t P AL 5Y FiS I S PART ID EC"T AddFr the following hove been done. you mus, Cnd+Cete tithier 'Y*10 or "Na" as to ee No ro de d by the owner, OCC-ulPant, or Boars Purnprng in#or�netian was p �, d f�r rt �aaet t o N one of the sYetem components �+a�++ been pumped *�* ��� been int rates during that period. L*rga Volomos of inspection. As bu wxt plans have been obt*ined and examined. Note if they *re r The 1e6MY or dwelling wellin was inspected I()' signs of sew ege back-W , The system does not reoewe non•sanitary or industrial gra$ts floe++. The site was inspected for sigfis of breakcOut. All syslern components,onents, excluding the Soil Absorption Systam. 1181 opened, ant! the int*Ric The septic tani� �ar�hoCes Were �noovered, ode t� of liq��d. dept dimensions,or to es, meteraet of construotion. �ys�e� ori tie site he The! siva and loCetion of the Soil Absorption Existing information. for exampter Pl*n at 1_-4. _._ s.:rMf:* #Plated to Part SUBSUftiFACE SEWAGE uMP04SAL SVSTEM INSP1 PARI C ySTEM NFFOR TION a 4 'a FLOW CONDMONS edro s fsi rx}: 111urnber of bedroorns lectusl}:� 1GN flow cUrfan1t rssrdertts, `. 74-f- - vinder IYes ar r'o): s stern) e3 or no}; 11 fires. seperete ir�s�e 'tian required separateY ,ystern inspected fires or na} use 1 Ye s of no)"-- eteT modmgs, if s ilsbl+e {18x1 two ye sr'� usage f�p�}: �.� rnp {Yes or no): 01� f ocou ency: ' . Ft l l�1IN1 l TI MAL: establishment: d t 9esed on i 5. 03T low .1 design 1ROW :lap present,. (Yes of niD)� rI este Hold ;sok pir " t: lye: or no1� ,itsry Waste 4isoh to the Title 5 systern: (yes or no)- -tete r r eedin ersiSable: of �p anc y:_�� . (Des ibel to of occupancy: GENERAL INFORMATION PART C SySTEMRMA A -. Mspectj on; DA G SEWEIR, )n site ptilinI ,.low grode: Of cor+s ruction: cost icon � +40 PV Other i��plaifi1 rt #row j+r to watler eupPly welt or suctIOn line ' .•.- ��rid* C11 'Of *a1���e, etc. rets. (c onditt of Ioit�t f venting. i.. r TANK, , on site plan) :,flow grade'. _�� Mete4 Fibe 1918 SS polyethylene W�Qther(e y1 of constrtictiorl: concrete of Co�pltiarIct R Y e 5 4 metal, kst age � IS lige Confirmed by rrtificat� !i ares' �+ e from tai of sludge to bo#tO{n of o,�tl�t tee or b�f#1� :�� � � r$ thickete s s= titi ti fr rte top of to tip of cutlet let or 7 e from bottom of scum 1c ottani of o let e o , dimensions were determined: _—A .,oLatr want or berms . +dep" r.uBSURFACE SFEWAGS DISPOSAL SYSTEM WSPE1 PAR'S C SV WATION (464=161 004 p 47 f ✓111 -i- 01 7&nk roust be PUMPed PTiOr to, at at tirne of, inspectior, pit* ptsn+ W grads.., 16 MOWCass pCIygthy%n* gallons, gent------- No_ !I-, arm in wockin order: Yes evious ping: s: d� f inlet tie, con ion 'of &,arm and float switches etc . JT10W B _pNtA�,, n vte Plaml liquid levet aGove gutl et invertp.,4... • �_ �__ s# IialraMS SUBSURFACE SEEPAGE DISPOSAL SYSTEM fNS# PART C SYS IN IwAAinoN ice"nuk SORPMN SYSTIEM AS IS n site Plan. it possible; excavation not required, location may be approximsted b :ated, explrin: leaching pits. number: leaching chambers, number:.,. Poaching gelleries1 number: ---�-- �. leaching trenches, number, irngth: leaching fields, number, dimensions: overflow cesspool, number: Axtermative system: Deane of Technology: �nts M of $0, ns of hyr rati�� fai4ure, level of ponding. damp � edition _-Ij ' t" X `DOLS: on site plan) ,,r and conf`igutation; top of liquid to inlet invert: of solids layer, R FA CE rAE C) AL SYS INS USB PART C YS PIPOR TION . ,, ' V �4 jo h Repo[ niome 5 oit T ps, T ypiCel depth #vrur� r�+stet 1)at.0 website visited e�1c�� �a+aP �bser,�btiar� N[Is cls h��l��r �Aadar��� Gr,Dundwatef depth. 'Shallow Wells t Feet d Depth pdr�r atr _ t4igh tour�d�r+eter rtidLitate Xsl the mtIhOlds vsed t det rmyn 4 va�iC : �t�i�e� fr��► �esi�n PI-mns O:n rec;vtd �t�sarvat�an basement 'sump ttc.] b s erve d fit (Aburling property, )el.ermined from 10CRI ;Dn"'Ortl :hecked with I cal acpafd of heRIth C:hec k ed FEMA Maps