23a-196 (7) 43 BEACON ST BP-2020-1238
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23A- 196 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Aboveground pool BUILDING P E R M I T
Permit# BP-2020-1238
Proiect# JS-2020-002094
Est.Cost: $9798.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO.-
Const.
O.Const.Class: Contractor: License:
Use Group: TEDDY BEAR POOLS & SPA 111889
Lot Size(sq.ft.): 27660.60 Owner: JESSICA SAALFIELD
Zoning. URB(100)/ Applicant. TEDDY BEAR POOLS & SPA
AT. 43 BEACON ST
Applicant Address: Phone: Insurance:
41 EAST ST (413) 594-2666 () Workers Compensation
CHICOPEEMA01020 ISSUED ON.6/19/2020 0:00:00
TO PERFORM THE FOLLOWING WORK.-ABOVE 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 Occupancy Signature:
FeeType: Date Paid: Amount:
Building 6/19/2020 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
C-; J
m
Z (ter The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
= 1� i Massachusetts State Building Code, 780 CMR MUNICIPALITY
- USE
ED Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
p y o One- or Two-Family Dwelling
U This Section For Official Use Only
2 Buildi it Number: o�a- Date Applied:
`oL A
-
'm
in mg fficial(Print Name) Signature VV D te-
SECTION is SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel NumbersC
43 Beacon St -(,(f/
1.1 a Is this an accepted street?yes_o no Map Number Parcel Number
1.3 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
o, v ` 2,01
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Private❑ Zone: _ Outside Flo d Zone? Municipal�1On site disposal system ❑
Check if yes
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Jess Saalfield Florence, MA 01062
Name(Print) City,State,ZIP
43 Beacon St -- - 5613086725 - JGAA(Flfc j11P,6M I L- �
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other [✓ Specify: POOI _
Brief Description of Proposed Work2: Above Ground Pool
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:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees: $
1 99 � Check No. Jheck Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full 0 Outstanding Balance Due:
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 Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 111889 02/08/2021
Teddy Bear Pools & SDas HIC Registration Number Expiration Date
HIC CompanyName or HIC Registrant Name
41 East Street
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 pen-nit.
Signed Affidavit Attached? Yes ..........E] 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 & Spas
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW 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.
Stephen Otto 6/7/2020
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. 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.mga,i.gov/oca Information on the Construction Supervisor License can be found at www.mass.govicips
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"maybe substituted for"Total Project Cost"
The Commonwealth of.tMlassackusetts
Department of Industria(Accidents
a 1 Congress Street,Suite 100
Boston,K4 02114-2017
www mass.gov/dia
VVorkers'Compensation Insurance Affidavit:Builders/Contractors/la lectricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant.Information Please Print Legibly
Name (Business/OrganizatiorAndividual):Teddy as
Bear Pools & Spas
P
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):
1.✓a I am a employer with 100 employees(full and/or part-time).* 7. ❑New construction
In I am a sole proprietor or partnership and have no employees working for me in $. Remodeling
any capacity_[No workers'comp.insurance required.]
3. l am a homeowner doin all work myself 9. ❑BuDemolition
lth g a
g y [No workers'comp.insurance required.]t
4.❑i am a homeowner and will be hiring contractors to conduct all work on my property. I will ]0 Building addition
ensure that all contractors eiffier have workers'compensation insurance or are sole 1 LE]Electrical repairs or additions
proprietors with no employees.
12.n Plumbing repairs or additions
5.rJ I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.QRoof repairs
These sub-contractors have employees and have workers'comp.insurance.)
6.Q We are a corporation and its officers have exercised ftir right of exemption per MGL c. i�-0 tither PO01
I52,§1(4).and we have no employees.[No workers'comp.insurance required.]
*Any applicant 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 must submit a new affidavit indicating.such.
tContractors that cheek 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 employ€es,they must provide their workers'comp.policy number.
I ant an employer that is providing workers'compensation insurance for my employees. Below is thepolicy andjob site
information.
Insurance Company Name:HUB International New England
Policy#or Self-ins.Lic.#:WC 8665063 Expiration Date:04/01/2021
Job site Address: 43 Beacon St City/state/zip:Florence, MA 01062
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 ORDERand a fine of up to$250.00 a
day against the violator.A copy of this statement may be fonvarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties of perjury th at the information provided above is true and correct
Si attire: Stephen Otto 6/7/2020
----. _._Date.___.........._..__.._____._.
Phone#: 413-594-2666
Official use only. Do not write in this area,to be completed by city or town officiaX
City or Town: Permitucense#
Issuing Authority(circle one):
1.Board of Realth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person. Phone#: _
Teddy Bear Pools, Inc,
(� 41 East Street * Chicopee, MA 01020 a
(413) 594-2666 * (800) 554-BEAR
+! ! FAX (413) 598-8823 4c
�� Home Improvement Cont. MA 0118891CT #520951
v
eJ/� ��a!i�1°�i/���.�/t1��2�2.�eY'G2'��t��e�i%��L �t%✓iLGC%tF%t�ilei�'
Office of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
"-M3k S
Type: Corporation
�'. Registration: 111888
TEDDY BEAR POOLS&SPAS INC "gip
41 EAST ST Expiration: 02!07/2021
CHICOPEE,MA 01020 :
.:�,,� Vis`.:,•
Update Address and Return Card.
cA i t: cr„-(I n
�D � p� �i�,( �q (� �” j�7�,pip g �p p
P:�R'J'16��IC�N'H' O�Aj, 9_yOI y��4��M® R JI�I[0�ldr�y�.C110N
b
lic it ktiown that
TEDDY BEAR. 130OLS INC;
41 EAST ST
CHICOPEE, MA 01020-2605
has tiallsiicd thc'qualificafiow; rcquu'ed tis• law Sltld is hereby rcgistci-(cd
,r
HOME IMPROVEMEN`r CONTRACTOR I ''
I
Registration # HIC.0520951
a
E r Effective: 12/01/2019
Ex' pirat om 11/30/2020 W >
Michelle seagull,Commissioner
FAM.
TEDDBEA-01
CERTIFICATE LIABILITY INSURANCE
DATE o/YYYY)
OF L
_ _ ai2r202o
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(les)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).
C TACT �
PRODUCER
HUB International New England LLC PNorV _.._._.__.._... .�___.__.__.. FAx _......
1070 Suffield Street2d3-8134 —�µ�c;#,,(413)739-9639
Agawam,MA 01001pRg3; $
I INSURERL.O.AFFORtMNfinCOVERAR ,,_,„_,,,,„_ NAICif
............_-_._._..__—_______ __ INSURER A:Central Insurance Company..._..._..__... _ 20230 t
INSURED fes§ !tAR0:Arbeila Protection Insurance Company17000
Teddy Bear Pools Inc. `uN, 8UReRc. ___
41 East St „LNSURR D
Chicopee,MA 01020 !w #
I 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 CONTRACTOR 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,
INSR ADDL SUER —— ------ POLICY EFF POLICY EXP g
LTR TYPE OF INSURANCELI=YOU POLICY NUMBER LIMITS 4
A X COMMERCIAL GENERAL UIBIUTY EACH_O�C„ E 1'000'000
CLAIMS-MADE X OCCUR CLP 8666062 4/112020 4!1/2021
TO R
OAMA E ENTED 300,000
p EXP(Any oneperson 10'000
_..............._ PERSONAL&ADV iR&RY 111 1,000,000
_GEMLAGGREGATE
pLIMIT APPLIES PER: GENERA AGGREGATE 2'000'000
JECT ❑ ....__.........................0,
PDucY Loc 2,000,000
PROQy„�T3�QOMPlOP _......._......................
OTHER:
B 'AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 11000,000
r ANY AUTO 1020086363 7/1/2019 7/1/2020BODILY INJURY(Personl
i.._..... OWNEDSCHEDULED
i AUTOS ONLY X AUTOS BODILY INJURY(Per accidently$
����pp pIN�+NNEp
x ATOS ONLY _X._ At/T05 ONLY P�t�OaE�R DAMAGE
i
UMBRELLA UAB OCCUR_— EACH OCCURRENCE
EXCESS UAB CLAIMS-MADE AGGREGATE
DED IT RETENTION$ —
A WORKERS COMPENSATIONPER DTH-
AND EMPLOYERS'LIABILITY YIN 8665063 4/1/2020 411/2021 X600,000
X 8I9 —1 — i
i
ANY PROPRIETORIPARTNERIEXECUTIVE ( E.L.EACH ACCIDENT i
OFFICERIMEMBEREXCLUDED? N NIA
1 andato in NNHH)) 500,000
I yes,describe under E t;_DI,SEASE�EA EMPLO _..........
IDDESCRIPTION OF OPERATIONS below E.L.DISEA -POLICY LIMIT 600,000
1
i
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached It more space Is regWr*O
i
q
9
1
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
For Verification of insurance Purposes Only THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
P y ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
ACORD 25(2016/03) 01988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Above Ground Pool
Plot Plan
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The plot plan below is approximate measurements for the pool placement at the home of:
Customer Info: ��7 ✓AA (-( I ,b \
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In the City/Town of: �.,�►�.��/� - Oji%co
Above ground pool set backs are: Oof ouse �i�c Side �i� Rear Septic Leach Field
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Draw out you backyard including the back of your home and lot lines. Show measurements from lot lines, both sides and
rear as well as from the back of the house. (See example on back of page//).
This a was completed by: Date: Z
41 East Street * Chicopee, MA 01020 * (4 13) 594 2666 * (800) 554-ESE - www.teddybearpools.com