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28-054 (8) BP-2022-0213 616 RYAN RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 28-054-001 CITY OF NORTHAMPTON Permit: Swimming Pool PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2022-0213 PERMISSIONIS HEREBY GRANTED TO: Project# Contractor: License: Est. Cost: 8000 JELLY BELLY'S POOLS and SPA Const.Class: Exp.Date: Use Group: Owner: KMETZ LISA D Lot Size (sq.ft.) Zoning: WSP Applicant: JELLY BELLY'S POOLS & SPAS, I NC Applicant Address Phone: Insurance: P O BOX 936 413-568-1700 WWC3535999 WESTFIELD, MA 01086-0936 ISSUED ON:03/10/2022 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: Gas: Final: Final: Rough Frame: Rough: Fire Department Driveway Final: Fireplace/Chimney: Final: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: • f 4 . Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner t z 0.4 L i �`' / :, / 14? , 1/" y) -. The Commonwealth of Massachusetts ;',,D, �4�� 'W � Board of Building Regulations and Standards'''TE^r,,/ FOR. a 4)/4, ICIPsALITY Massachusetts State Building Code, 780 CMR •,,h), �,^, ti• •c„ USE Building Permit Application To Construct,Repair,Renovate Or Demoei 10 s evisedMar 2011 One-or Two-Family Dwelling \\-. This Section For Official Use Only Building Permit Number: b#oial'aV Date Applied: 4-t}h•-) s-; l'//Z 3-Iv-Z6Z2. Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 PropertyA1nddres�d 1.2 Assessors Map&Parcel Numbers � . 00 o\to g ag .03 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Prone ty 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 Wate Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Y Private 0 Zone: _ Outside Flood Zgne? Municipal[R/On site disposal system 0 Check if yeslif SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: LiSCI*N r t 1.. c\pr tr1C.-Q,MA ( Ns ik0Z Name(Print) City,State,ZIP tiar. NizIn iktzgark tk •Viq5-stile 16o..Ksz4zoaa Ur •Cor . No.and Street Telephone Email Address U SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied ❑ Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 9ipecify:Pklpp .cyoUnd9SA Brief Description of Proposed Work': \ys,151cpAtiktipn pc P. \' ' X 52" AboV is sv Und SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ "ACstIQ 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee \pA:0 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ _Suppression) Total All F,ee/s: a 4/Check No 4"Check Amount: IOCash Amount: 6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expirati ate Name of CSL Hol e List CSL T elow) No.and Street ype Description U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted l&2 Family Dwelling City/Town,State,ZIP M Masonry R Roofing Covering WS and Siding SF Solid Fuel Appliances Insulation -hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) \211,`a2G Iq�22 Se.\\ '�e-\.\\-S% \3 �9 \(%c? . . HIC Registration Number Expiration Date HIC Corn nv Name or HIC Registrant Name $ Soda w�c� �oc�.+c�► tseN QGcV @ oot.Um No.and Street 'Email address VIt%/6 c\d. .MA o\0481s 413-Skit-11C+3 City/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 No 0 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 "e\\y trawi'S QCYJ`S S47eQS \r c_, 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: 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. 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.gov/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 half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" CITY OF NORTHAMPTON SETBACK PLAN MAP: a LOT: 'g - X54- O O 1 LOT SIZE: 1 WI REAR LOT DIMENSION: REAR YARD v �-/ IN K �'> /i .-:__- -z_z_ -c-t --;--, 77 .- T, t, 1 t \\( SIDE YARD SIDE YARD L-2) -0. rt„. i ,„ .. ---t- _ rc ___ . .... ,. ,_ , cp N ._ O. ‘L' --- -4> C t , .-/.-- ----------T2L7 ' `__ .„..._...„___ FRONT SETBACK FRONTAGE City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street 40 Municipal Buildings Northampton, MA 01060 CO TRUCTION DEBRIS AFFIDA ' T (FOR ALL I MOLITION AND RENOVATION P OJECTS) In accordance of the provisions of L c 40, S54, a conditio .f Building Permit Number is that all •ebris resulting fro, this work shall be disposed of in a properly licensed waste disposal facility, . . defined by GL c 111, S 150A. The debris will be disposed of in: Location of Facility: The debris will be trap`sported by: Name of Hauler/ F i t i Signa re of Applicant: Date: The Commonwealth of:bfossachusetts * , ! Department oJ'Inrlustrii:I Accidents �I_ 1 Congress Street,Suite 100 a iJi`� r Boston, MA 0211.1-2017 /.7 wiviv.n: ss.g,os%dia 'r1 aikcrs'compensation Insurance Affidavit:Buildersl't'ontractorsO'E1ec1riclans/Plunthers. TO B}:FILE SS 11H'flex:PERM)CITES ;Al rtHOttI"1'l Applicant Information Please Print Leeihlh Name(Husirw ;organ uzatiorviori viduaI): �� V.S•5%N�J .� S Address: `-::) , SrZ[ SZtC.t — Cityl/State/Zip:_\Ag,Skc\ Phone#: '- b - 4% - »Ov--- Are you an employer?Check the appropriate bus: Type of project(required): 11;11 our a cnipI V T with ,\ e113p1L' Ca{full rod or pa t•ti ttic t_' 7. ®New construction 201 am a sole proprietor or partnership and hay c no employees working forme in g, CI Remodeling any capacity_[Nu workers'comp.uuuiano required.] 3.1:1 1 aril a homeowner doing all work myself.[No wrka7a u 'comp_irouranix requioal_]" 9. El Demolition 4.0I am a luniwrer and will be hiring euidractur>.to conduct all wurk on my property. 1 will 10®Building addition .ri ciehtin:that all N!iltiae'lura.:ither have Winkera'conipca alum hour ix or an sale 11.0 Electrical repairs or additions pm upricton w lib nu eiapkivm _ 12.0 Plumbing repairs or additions S I am a Alicia]euntractur and I have hired the sub-cuntraciun listed on Ilse attached shed_ 130 RoutThese sub-contractors lowcmpluymxs and have winters'crimp.uuurunce:' repairs 14.[ Other�bCNIC VC.Un �► 6.D Vi'c arc a corporation and it.,officers have eaerrix�d heir nglm of cacttipitimxt per MCiL c. ��\ \��" 15'_.Q 1p4i,and we ir:ave nu eripluaccs.[Nu workers'comp.insurance required.] 'Any apptic a that cluecks boa ire nimbi also till not epee section heluw show ins their workers'compensation paltry infwrnatiwi_ +Homeowners ask,submit this atfnlavit indicating they arc doing all work and then Luc unsaid.:cuuprrcwrs rnUai submit a ucu aliwtal ii indicating aucli. ;C"uutructun Mat check This host must att.alr:d am additional abed ahuwiug lei:name tit thtc aul--cuarrtctor,and gate wluehhcr ur nut Muse mecca lra.e cc,.. It tlx:sub-cwitracinis Ita,e cnmpl. cc,.they mod pm%idc their nolo&coup.policy'mamba. 1 dill an employer dirt is proridin,,workers'compensation insirunce for my employees. Below is the police and job site information_ Insurance Company Name:Wg SCSJ ��t15V►`CQY1lCt CC'�f`r1flC`s f17— — Policy#or Suit=ups.Lic. Expiration Date: 1 k i 1 ZZ Job Site Address: \\! ckCN. City:State;.+Zip:cxQrenzz MA_CACA92.. Attach a copy of the workers'compensation policy declaration page(shossing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a face up to SI.S0 .00 and or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 a day against the v iolator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I dry hereby(rrtiftr under the pains unit penalties of perjury that the information provided above is true and correct. Date: Phone g: Official use only, Du nan write in this urea,to he completed by cite'or town official. City or Town: PermitLicense Issuing Authority(circle one): L Board of Health 2.Buildiint Department 3.Cityfrovtn Clerk 4.Electrical inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: City of Northampton Sic, Massachusetts S. w= * DEPARTMENT OF BUILDING INSPECTIONS 4% ` .4 • 212 Main Street • Municipal Building y. Northampton, MA 01060 1 `PS'k _ ,j\'�a t OMEOWNERS'EXEMPTION ELIGIB ITY AFFIDAVIT I (insert full legal name), born (insert month, day, year), hereby depose and statS the following: 1. I am seeking a building per ..t pursuant to the ho eowners' exemption to the permit requirements of the Massachusetts State Building C.•e, codified at 780 C' R 110.R5.1.3.1, in connection with a project or work on a parcel of land to which I hold legal itle. 2. I am not engaged in, and the project o work fo which I am seeking the aforementioned homeowners'exemption, does not involve the field erection of ma • act red buildings constructed in accordance with 780 CMR 110.R3. 3. I qualify under the State Building Code's .e•nition of"homeowner"as defined at 780 CMR 110.R5.1.2: Person(s) who owns a parcel of lane on ich he/she resides or intends to reside, on which there is, or is intended to be, a one-or two-fa ily dwe ing, attached or detached structures accessory to such use and/or farm structures. A perso. who const cts more than one home in a two-year period shall not be considered a home owner. 4. I do not hold a valid Massacl setts construction su rvision license and, except to the extent that I qualify for and will abide by the Massa usetts State Building Co 's requirements for the supervision of the project or work on my parcel, I am not e gaged in construction supery ion in connection with any project or work involving construction, reconstru ion, alteration, repair, removal o demolition involving any activity regulated by any provision of the Mass husetts State Building Code. 5. If I engage any o er person or persons for hire in connectio with the aforementioned project or work on my parcel,I acknow edge that I am required to and will act as the su rvisor for said project or work. Signed under the pai s and penalties of perjury on this day of , 20 . (Signature) Page:25 of 34 2022-02-11 15:27:45 EST 14136474046 From:Rosemary Dinatale -------"`t1 JELLBEL-01 RDINATAL 4 CCO�--RCr CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDYYVY) 2/11/2022 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 License#1780862 coNreeT Rosemary DiNatale HUB International New England PHONE FAx 96 Shaker Rd {A/C,No,Exl) I(AIC,Nui: East Longmeadow,MA 01028 E-MAILDSS.Rosemary.dinatale(mhubintemational.com INSURER(S)AFFORDING COVERAGE NAIQ71__-___ INSURER A,Regent Insurance Company 24449 INSURED INSURER B:WeSCOInsurance Company 25011 Jelly Belly's Pools&Spas Inc. INSURER C PO Box 936 INSURER D Westfield,MA 01066-0936 ----. ------------_-____---_____._--_� __.----_- 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 WTH 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 AWL SUER LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF POLICY EXP (MMfOD1YYYY1 IMId70D/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE [4IOCCUR BPK0004797-02 7/1/2021 7/1/2022 p asrLEaoccunDEce) 100,000 MED EXP{Any one person) S 5,000 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY I I PE� I 1 LOC 2,D0o,000 PRODUCTS-COMP/OP AGG $ OTHER S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT {Fa accidantl 5 ANY AUTO BODILY INJURY(Per nerson, 5 OWNED —^SCHEDULED AUTOSRR ONLY Auras BODILY INJURY(For acciduntL S AUTEOS ONLY AUTOSONLY PROPERTY DAMAGE {Per accident) $ S UMBRELLA LIAR OCCUR EACH OCCURRENCE 5 EXCESS LIAR CLAIMS-MADE AGGREGATE S DED RETENTIONS 4 B WORKERS COMPENSATION X PER X OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIEI'ORlPARTNERrE'XECUTIVE (N INWC3535999 7/1/2021 7/1/2022 1,000,000 I I E.L.EACH ACCIDENT OFFICER/MEMBEREXCLUDED? N N/A �_._ (Mandatory in i ) 1,000,000 E.L.DISEASE-EA EMPLOYEE S II yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101:Additional Remarke Schedule,may he attached if more.space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Lisa Kmetz THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 616 Ryan Road Florence,MA AUTHORIZED REPRESENTATIVE ?1, , 17:- ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD