043-073 BP-2022-0382
120 DUNPHY DR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
43-073-001 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-2022-0382 PERMISSIONIS HEREBY GRANTED TO:
Project# ABOVE GROUND POOL Contractor: License:
Est. Cost: 9000 JELLY BELLY'S POOLS and SPA
Const.Class: Exp.Date:
Use Group: Owner: BURNS WALL LISA M& MARY T
Lot Size (sq.ft.)
Zoning: WSP Applicant: JELLY BELLY'S POOLS & SPAS, INC
Applicant Address Phone: Insurance:
P O BOX 936 413-568-1700 WWC3535999
WESTFIELD, MA 01086-0936
ISSUED ON:04/14/2022
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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: I
. • , ' y- •
Fees Paid: $40.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Buildinu Commissioner
File #BP-2022-0382
APPLICANT/CONTACT PERSON:JELLY BELLY'S POOLS &SPAS, INC
P 0 BOX 936 WESTFIELD, MA 01086-0936413-568-1700
PROPERTY LOCATION 120 DUNPHY DR
MAP:LOT 43-073-001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Building Permit Filled out
Fee Paid $40.00
Type of Construction: ABOVE GROUND POOL
New Construction O
Non Structural Renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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 SpecialPennit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Perm its Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic ApprovalBoard 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
ZOZ2
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.
r
ECG J
The Commonwealth of Massac sett APR i 2
w, Board of Building Regulations and tan rds 2022 k'OR
IF': Massachusetts State Building Code 78 . ICIPALITY
•
'vow,-&itILD/NG USE
Building Permit Application To Construct,Repair,Re-en ^i�et� �drloNsRevi ed Mar 2011
•One-or Two-Family Dwelling 'oso
This Section For Official Use Only
Buildinn Permit Number:Nuss
� Date Applied:
Kegir•-) /K //l 11- 1LI Z627_
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
QC)PurQhy oyiNt. y 73
1.1 a Is this an accepted street?yes no Map Number Parcel Nurtiber
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
Required71P111
Requiredded 1L Required Provided r
1.6 Niter S (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8
Public 0 Private CI Zone: _ Outside Flood Zone? Municipal❑ On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP1
2.1 Owner'of Record:
M rr-g c\cIve rC e,MA c c 2
Name(Print) City,State,ZIP
\20 ur\i y p.-:Ye y\3 320 u211
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building❑ Owner-Occupied 0 Repairs(s) ❑ Alteration(s) ❑ Addition 0
Demolition 0 Accessory Bldg.❑ Number of Units Other CloSpecify:Aojvt9 nd'k,
Brief Description of Proposed Work':\evsksa \ptiCx- C 0Q 2.1 ' X S2" Q,bpve:scuan d
?ooA.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ $00O 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ CI Standard City/Town Application Fee
OGI2) 0 Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All Fees r jh
Check No. eck Amount: 1 V Cash Amount:
6.Total Project Cost: $ Q1p+O0 0 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5. nstruction Supervisor License(CSL)
License Number Expira ate
e
Name of CSL Holder
List CSL Types ow)
No.and Street Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
City/Town,State,ZIP `R Restricted 1&2 Family Dwelling
Pt Masonry
RC Ro Covering
WS Window a 'ding
SF Solid Fuel Burning 'ances
Insulation
Te one Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
Q\s S s Inc. IC ►2� $x�► n Date
7 y � HIC Registration Number Expiration Dat
HIC Company Name or HIC Registrant Name
5g Sa aWNNyi N gLOo d ibe.\\v�QO\ Q Co‘.com
No.and Street Email address
't. c itXta rarA. CA08 y13-5108- \100
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 13ceNo ❑
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 'S�\ ti ,\\\,1% SiC7JAS
to act on my behalf,in all matters relative to work authorizedy this building permit application.
ifV\PcFN. 'F'AM2-65 \\ \Ili
) -Owner's Name(Electronic Signature)
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 applicatio 's true and accurate to the best of my knowledge and understanding.
\tom ;
int Owner's or Au of d Agent's g nt's Name(Electronic Signature) ate
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"
The Commonwealth of Massachusetts
—;;10 f . Department of Industrial Accidents
.441s R 1 Congress Street,Suite 100
rah is Boston,MA 02114-2017
-„ wwwmass govidia
II-osiers'Compensation Insurance Affidavit:Builders`ContractorslEkctriciansfPlumbers.
TO BE HEED WITH THE PERMUTING AItTHORITY.
Anpllcsat Information Please Print Leeibly
Name(uur+Mnc Orpnvationlndividual): 3t\\j '�t\\\3 Ro0\'
Address:
City/State/Zip:weScE S tx ,.MA fc .\szsb Phone#: 'X -5195 -\\OO
Are yr.a■easpi yore Cheek She appropriate hmm:
Moe atPr'akM(required),
1. 4 im a employer with A______emplopeon(mp amdbr part-time)• 7. D New construction
2.0I aka a sole pnipriour or patmteohi,and have no employ ors working hem it $. Remodeling
any capacity_(No weatcrs'comp.inenemor required-]
30 I am a homeowner Joins all wart mayelf.IN o workers'romp.Mu =required", Sl• ❑Demolitione
4.0 l am a le►reaorwnrr hiring will be hg contractors
eu conduct all weaken any y properly. I will 1013 Bnitding addition
ensure that all a srractors either have notices'memorisation in inxrrramoe er ate iota 11.0 Electrical repairs or additions
proprietors with no employees_ 12E1 Ding repairs or additions
501 am a Birtral coritrector and I have hired the x b-etinurwme listed em the ansehd short.These1 ❑Roof
silo-e.'ontractuts have employees and hart winters"amp.irmnsmee t a
airs
6.0 we are a evaporation and its officers have exax M crsed their right of exerapriur per IL e. 14.Mather A�\OCIVZ Qe(O\C—e
152,§1(4),and we have no re employees.(No winters"comp.insurance required" `W\
•Amy applicant dal chocks boa el rivem err till out the mains bay*showing their week&ootnpamnlian parity infbrtmtdom.
$Harmaowaera who submit this affidavit Mace*they are doing all work madame Me amide rim I..ramra num WM*a amr+affidavit inditatiozeith.
h3esermca that check this box must nelried as eddilierol eon showing the anus true amb ceommotsaed sear trdrelbo at mat dross entities have
em loyeem lithe soh-contractors have employers.they nisi provide their workers'map.palsy ramber-
I mar an employer that is providing workers"compensation insurance for my employees. Below is the policy and Job site
information.
Insurance Company Name: \1�125CS �Y15\�►`(O.`CICe. CS�YY`t,-x>�,\. —
Policy#or Self-ins.Lie.#: w�C`��?�C? C) Expiration Date: c)-1 k Q
Job Site Address: \2:;.> `QV;Y1Q\C s \ QY\i . City/'State/Zip:E'\pY-c.ir-ce MA G\C'\9Z
Attack a copy of the workers'compeusides policy declaration page(showbog the policy amber and eipiratioa date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to S1,500.00
andfor 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 awl p n. ,s fperjwy that the information provided above is tare and correct
Si tutu: o�/t/LQ,.,Q J Date:
Phone#: 41') flog 11 n C�
Official use only. Do not rite in this areaa,to be completed by city or town official
City or Town: PermitiLicense#
Issuing Authority(circle one):
I. Board of Ilealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
(s.Other
Contact Person: Phone#:
,�`,Y;E``y JellyBelly's 5 iN3
1 Pools & IncH Spas .
58 Southwick Rd. • P.O. Box 936 • Westfield, MA 01086-0936 • 413.568.1700 • Fax 413.572.1218
www.jellybellyspoolsandspas.com
Agreement of sale and installation between JELLY BELLY'S POOLS & SPAS INC.:A Massachusetts Corporation, (hereby designated
and referred to as DEALER)and \`-\ -v,-rS
and
(hereinafter individually and collectively designated and referred to as OWNER) of(Street)
(City&State) cSl\cl:;i`C2 `C1CC \Yl'A CZ\n\c2
(Business Address) \24ZM
(Home Phone) V,\'s-1 320 .o2 \\
DEALER and OWNER hereby mutually agree and contract that DEALER shall sell and install at the home address of OWNER shown above
the product(s)stated below, and OWNER shall pay to DEALER for same the total due DEALER in accordance with the terms noted below.
21 k CJZ" W \ \\C'`CC' � �M` r
\rot\��,
-\%\ MCA pz \ 1 1\c.•
TOTAL FOR MATERIALS \\QG p`
SUBJECT TO ALL TERMS AND SALES TAX 31ao \`=\
CONDITIONS ON REVERSE INSTALLATION 3vC.)
SIDE HEREOF. \ LOADS OF WATER @ \ 2 JELLY BELLY'S POOLS & SPAS, INC. INITIAL LINER MAINTENANCE
IS NOT RESPONSIBLE FOR INJURIES BOOSTER APPLICATIONS PER YEAR
DUE TO MISUSE OF POOL. TOTAL \-110. \Q1
NO DIVING - NO JUMPING CASH DEPOSIT y51.o5. C7Rg
DUE ON DELIVERY
The undersigned,jointly and severally,agree that this contract includes the above terms,conditions and specifications,as well as those on the reverse
side hereof, all of which are incorporated herein, and constitute the entire agreement between the parties, and further acknowledges that they have
read and understood the entire contract and has received a copy hereof.YOU MAY CANCEL THIS AGREEMENT IF IT HAS BEEN SIGNED
BY A PARTY THERETO AT A PLACE OTHER THAN AN ADDRESS OF THE SELLER, WHICH MAY BE HIS MAIN OFFICE OR
BRANCH THEREOF, PROVIDED YOU NOTIFY THE SELLER IN WRITING AT HIS MAIN OFFICE OR BRANCH BY ORDINARY
MAIL POSTED, BY TELEGRAM SENT OR BY DELIVERY, NOT LATER THAN MIDNIGHT OF THE THIRD BUSINESS DAY
FOLLOWING THE SIGNING OF THIS AGREEMENT.
SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT.
This sha t ke effect as a s ale ' strument JELLY BELLY'S POOLS & SPAS, INC.
Signed Owner By 1`t\c II<Nt•
Sale Representative
Signed Owner JELLY BELLY'S POO S & SPAS, INC.
Date 3�2� 22 By 61(t.AAA.../A-.)
Duly A thorize
Valid when countersigned by an authorized Officer of Dealer.
NOTICE TO OWNER - Do not sign this contract if blank.
Jelly Belly's Pools & Spas, Inc. not responsible for damage to liner caused by inse ts4
Page:4 of 7 2022-03-25 08:40:09 EDT 14136474046 From:Rosemary Dinatale
JELLBEL-01 RDINATALE
`--.7R CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
3/24/2022
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 POUCIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(5),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 CONTACT Rosemary DiNatale
HUB International New England PHONE FAX
Eal; (NC,AX Nol:
96 Shaker Rd NE.
East Longmeadow,MA 01028 GDOREAl`
ss•Rosemary.dinatale@hubintemational.com
INSURER(SI AFFORDING COVERAGE NAIC d
INSURER A:Rerlent insurance Company 24449
INSURED INSURER B:Wesco Insurance Company 25011
Jelly Belly's Pools&Spas Inc. INSURER G
PO Box 936 INSURER D:
Westfield,MA 01086-0936
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 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 ADM SUBR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MNI(pO/YYYYI IMMIDDIYYYYI LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE i 1,000,000
CLAIMS-MADE TX]OCCUR BPK0004797-02 7/1/2021 7/1/2022 PREMISES(Ee occurIDenoe) (, 100,000
MED EXP(Any ono person) $ $,000
PERSONAL ADV INJURY 5 1,000,000
GENT.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE E 2,000,000
X POLICY JEp n LOC PRODUCTS-COMP/OPAGG $ 2,000,000
r"—
OTHER: $
COMBINEAUTOMOBILE LIABILITY (Ea accident)
INGLE LIMIT
ANY AUTO BODILY INJURY(Per person) 5
— OWNED — SCHEDULED
AUTOS ONLY _ AUTOSpNNQQ EEpp BODILY INJURY(Per accidoni) S
.__ AUTOS ONLY ., AUTQSONLY (Perr aWdent) MAGE
UMBRELLA LIAB OCCUR EACH OCCURRENCE S
EXCESS LIAB CLAIMS-MADE AGGREGATE ,
OED RETENTIONS _ S
B WORKERS COMPENSATION X PER X OTH-
AND EMPLOYERS'LIABILITY STATUTE ER
Y WWC3535999 7/1/2021 7/1/2022 1,000,000
ANY PROPRIETOR/PARTNER/EXECUTIVE �IN EL.EACH ACCIDENT S
QEFICERIM�M�F�i EXCLUDED? �" I N/A 1,000,000
((Mandatory m ) E.L.DISEASE-EA EMPLOYEE S
If yer.describe under 1,000,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 5
DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may he attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Mary Burns ACCORDANCE WITH THE POLICY PROVISIONS.
120 Dunphy Drive
Florence,MA 01062
AUTHORIZED REPRESENTATIVE
I
ACORD 25(2016103) CO 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
cc-a f • ,
tiive 4i'9y
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