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17D-014 (6)
6 GARFIELD AVE BP-2020-1284 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-014 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Above rg oundpool BUILDING PERMIT Permit# BP-2020-1284 Proiect# JS-2020-002150 Est.Cost: $5635.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: TEDDY BEAR POOLS & SPA 111889 Lot Size(sa. ft.): 11804.76 Owner: DI GIACOMO TERRY Zoning:URB(100)/ Applicant: TEDDY BEAR POOLS & SPA AT. 6 GARFIELD AVE Applicant Address: Phone: Insurance: 41 EAST ST (413) 594-2666 () Workers Compensation CHICOPEEMA01020 ISSUED ON.6/24/2020 0:00.00 TO PERFORM THE FOLLOWING WORK.-ABOVE GROUND 18X48 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 6/24/2020 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner o The Commonwealth of Massachusetts FOR z H Board of Building Regulations and Standards o c-- MUNICIPALITY _nMassachusetts State Building Code,780 CMR USE z K o I Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 zG ' One-or Two-Family Dwelling D N o This S ti n For Official Use Only '�'o Buil itlg Permit Number: Date Applied: oQ z Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Asses rs Map&Parcel Numbers 8 Garfield Avenue ( 0/ 1.1 a Is this an accepted street?yes ✓ 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 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Terry Di Giacomo Florence, MA 01062 Name(Print) City,State,ZIP 8 Garfield Avenue 413-262-7416 terrydWMcimail.com No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units I Other [✓ Specify: POOI Brief Description of Proposed Work2: Above Ground Pool (18' X 48°) 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;.V 5,635.43 Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ ❑Paid in Full 13 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 Teddv Bear Pools & Spas HIC Registration Number Expiration Date HIC CompanyName or HIC Registrant Name 41 East Street scotta6d�teddybearpools.com No.and Street Email address Chicopee, MA 01020 413-594-2666 Cit /Town, State,ZIP Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... 0 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. i i /Il,�m6 Sine 161 ZD 1 Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Scott Alexander 6/12/2020 Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program can be found at www.mass. og_v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 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 halfibaths 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" � Above Ground Pool Plot Plan The plot plan below is approximate measurements forth e pool placement at the home of: Customer Info: Terry Di Giacomo, 8 Garfield Avenue In the City/Town of: Florence, MA 01062 � n Above ground pool set backs are: House Side ��/ Rear Septic Leach Field 71 P e i F I f s 4 — ..m -— z _ J, a x i n i t .. i 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 plan was completed by: Date: A6 120W 41 East Street b Chicopee, MA 01020 • (413) 594-2666 • (800) 554-BEAR www.teddybearpools.com The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114--2017 www.mass.govfdia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE PILED WTTH THE PERMITTING AUTHORITY. Avylicant Information Please Print Legribly Name (Business/OrganizatiorAndividual):Teddy Bear Pools & Spa s Address:41 East Street City/State/lip:Chicopee, MA 01020 Phone 4:413-594-2666 Are you an employer?Check the appropriate box: Type of project(required): 1.❑✓ I am a employer with 100 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. E]Remodeling any capacity.[No workers'comp.insurance required.] 3.Q I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9: El Demolition 10 []Building addition 4.El 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 11.0 Electrical repairs or additions proprietors with no employees. 12.F-]Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.[:]Roof repairs These sub-contractors have employees and have workers'comp.insurance,t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL e. 14. ✓0 Other POOI 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 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 atm an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. Insurance Company Name-HUB International New England Policy#or Self-ins.Lic.#:CPL 8665062 _ , Expiration Date: 04/01/2021 Job site Address: 8 Garfield Avenue 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 ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct: Si nature:Scott Alexander Date. 6/12/2020 Phone#: 413-594-2666 Official use only. Do notwrite in this area,to be completed by city or town official City or Town: Permit/Ucense# 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#: Teddy Bear Pools, Inc. I 41 East Street ® Chicopee, MA 01020 a (413) 594-2666 * (800) 554-BEAR !� FAX (413) 598-8823 Home Improvement Cont. MA #11889/CT #520951 TWDVWARPOOLS.CWM Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation 111889 TEDDY BEAR POOLS&SPAS INC Registration: � Expiration: 02!07/22/07/2 021 41 EAST ST �t CHICOPEE, MA 01020 Y Y `vFys k Update Address and Return Card, CA 1 0 20M-05/17 SU E 4O,jrEf7�1(1( IN' 1w it krwwn thl It TEDDY.f.9"A R, POOLS INC � „ ASI > CHICO 1'Ei;t:, IVLt 01.J20-2605 . 4. hats satisfied the dualiFic-akOIIti t c(]i )Ircd by 1;tvV �t1,d is hereby rcpistered as a `. -1'M -{W] CONT RC l� i• r1TO1� 1i ( l Re ristratio ti 11 1 I1C1.0520951 Effective: 12/01/2019 Ex nation- 11/30/2020 - p y. Michelle ScaPll,Commissioner A w .. w ,. �a 1. e � e e � e e n,. . �".. . ,�. .•, .. .� i TEDDBEA-01 Ul ACORN' CERTIFICATE OF LIABILITY INSURANCE DAT4/2/2 D/YYYY) � 41212020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. 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 C NTACT HUB International New England LLC n"CN�J Ext); 800 243-8134 FnAX,Ne:(413 731-9539 1070 Suffield Street MAIL Agawam,MA 01001 SS: _ INSURER(S�AFFORDING COVERAGE _ NAIC It_ INSURER_A:Central-Insurance Compay20230 INSURED INSURERS:Arbella Protection Insurance Company 17000 Teddy Bear Pools Inc. 41 East St INSURER D: Chicopee, MA 01020 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXPLTR M rYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE E 11000'000 CLAIMS-MADE �OCCUR CLP 8665062 4/1/2020 4/1/2021 DAMAGE TO RENTED 300,000 MED EXP(Any oneperson) 10,000 PERSONAL&ADV INJURY 1,000'000 EN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 2,000,000 POLICY j LOC PRODUCTS- OMP/OPAGG 2'000'000 OTHER: _ B COMBINED SINGLE LIMIT 1,000,000 AUTOMOBILE LIABILITY g0 ' $ _ ANY AUTO 1020085353 7/11/20119 7/11/2020 BODILY INJURY Perperson) OWNED SCHEDULED AUTOS ONLY X AUTOOSwNED B DILY INJURY Per accident X AUTOS ONLY X AUTOS ONLY per Jdent AMAGE UMBRELLA LIAB _ OCCUR EACH C RRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE DEC) I I RETENTION$ A WORKERS COMPENSATION X I PER OTH- AND EMPLOYERS'LIABILITY YIN WC 8665063 4/1/2020 4/1/2021 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT _._..-...-...._...____ ppF�FICER/MEEMBEREXCLUDED? u N/A We in NH) E.L.DISEASE-EA EMPLOYEE $ 500'000 It yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) 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(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD