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43-077 (9) BP-2022-0670 57 DUNPHY DR COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 43-077-001 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-2022-0670 PERMISSION'S HEREBY GRANTED TO: Project# above ground pool Contractor: License: Est. Cost: 8000 JELLY BELLY'S POOLS and SPA Const.Class: Exp.Date: GIRARD KIMBERLY C&CHRISTOPHER E Use Group: Owner: GARNER 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:06/13/2022 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: Ti,4 I '1 / Fees Paid: $75.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner File #BP-2022-0670 APPLICANT/CONTACT PERSON:JELLY BELLY'S POOLS &SPAS, INC P O BOX 936 WESTFIELD, MA 01086-0936413-568-1700 PROPERTY LOCATION 57 DUNPHY DR MAP:LOT 43-077-001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Building Permit Filled out Fee Paid $75.00 Type of Construction: ABOVE GROUND POOL 10)14 New Construction Non Structural Renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans/Plot Plan THEFOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF MATION PRESENTED: Approved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Perm it With Site Plan Major Project: Site Plan AND/OR SpecialPermit 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 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 t i it ' w�;• .TI ,: 6 A 3 as Sill ature of Building Official 1 ( 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. REV The Commonwealth of Massach?CMR s JUN Board of Building Regulations and ar NMassachusetts State Building Code, 7ZICITY Building Permit Application To Construct,Repair, ' a R ised ar 2011 One-or Two-Family Dwelling °RMAMP pN INs o o roNs i This Section For Official Use Only _ Building Permit Number: Date Applied: • a' i S,, % 13 Building Official(Print Name) i Signature Da e SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 5-1 0 cn\ cvivc. 413 0 77 1.la 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) Required Provided Required I it.ProvidedL Required Provided 1.6 (M.G.L c.'+0,§54) 1.7 Flood Zone Information: 1.81.1.1ge Disposal System Publicif Private Zone: _ Outside Flood Zone? Municipal liK site disposal system F1-7 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: CY1r iStCJi* tr W,`(*r V \or'er-NCc , MA C .k Olga Z Name(Print) City,State,ZIP -6-k OvnQc y DrsNe__ W\3 28\ p-5‘03 No. and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied ❑ Repairs(s) 0 Alteration(s) ❑ Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other liiKpecify:A �1'1 'qCa Brief Description of Proposed Work': \etthtk\a pr% pF d \$' x 452.' Atc e_grcrnd SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ --tom 1. Building Permit Fee: $ Indicate how fee is determined: 0 Standard City/Town Application Fee 2.Electrical $ 0 Total Project Cost3(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5.Mechanical (Fire S Suppression) Total All F s: $ r/ Check Nota1B Clheck Amount: 74 Cash Amount: 6. Total Project Cost: S $C,. .) 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 struction Supervisor License(CSL) License Numbe Expiration Date Name of CSL Holder L Type(see below) No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State,ZIP Restricted 1&2 Family Dwelling Masonry RC Roofing Covering ow and Siding SFF ' gSolid Fu = n Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) \ 15 Ig 'Sce--k\y V-_k‘y s s;Inc• HIC Registration Number Expiration s. • HIC Company Name or HIC Registrant Name 'ikeZda 3t\\.�btX ?c �SC> o�\.cow-, No.and Street Email address w%."StFc�Xa.Mk p co k\3 kifit k-toc3 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 ❑ 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 't\\\_,‘ e)e. \3? C>V3 'fib er, to act on my behalf,in all matters relative to work authorized bytis building permit application. ahos 6/'Jzz.. ctronic 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 application is true and accurate to the best of my knowledge and understanding. i 7�Z e(Electronic Signature) 0111.1111 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 l' OP �! Department of Industrial Accidents ?(Il= 1 Congress Street,Suite 100 = 4 _ Boston,MA 02114-2017 www mass got./&a 11 others'Compensation Durance Affidavit;BuilderslContr ctorsiEkctriciamdPlumbers. TO BE FILED WITH THE PERMITTING At ITIIORITI. Applicant Information Please Print Leeib► Name tHusin ,Orgammtion''Individual): St.\\v ���' pc,c, S� aS C, Address: ram$ .a l`NC'eN 9..PC6 City!State/Zip: _St�Se\G MA Q\usS Phone#: y1'b 05\s$ V'\OC) Are yr s ai employee(leek the ippeopdate boo: Type of project(required): a m a employer with 1 employees(full maim part-tune)-' 7. 0 New construction 20 I am a sok peoprieiuror pottaeriip aid have no employees working fur me m $. Remodeling any t piiwtttdors" !-ietarorm .1 9. ❑Demolition lam a hormawner dais;all wadi nnyyriG[Nu'w ,kerx'comp-insifaraac required_] 4.0 I am a hammwnerarll1 w balking contractors to eunduiet all work on nf}'property. 1 will I0 a Building addition .monad der leadocoers either have anthem"cuanpensaeiirn insurance or are mule 110 Electrical repairs or additions peopeietors within employees. 12.❑Plumbing repairs or additions 5CI t on a gornera 1 contractor and I have hired the irb-contracture listed on the attached sheet Them atheontrxkers have err�ployees and bast wtiEiers'comp.i e frame.: 130 Roof repairs Th 60 We are a corporation and its officers have mi/rised their right of exemption per:MCi L r. 14.12tlither A p�V r�j' lSZ ti f l(4),and we have nu eutpkiworkers".[Nu workers"comp.insurance required.] s0C), 'Amy orpiment that diccks boa 81 nod also fill out the median below showing their workers'compensation'polity infion iim. f Beerraowien who submit thin affidavit indicating they are doing all'aisle and then hire mtsi&contractors cruse submit a saw affidavit indieetmg such. :Contractors that check this but mum atfachevl an additional sheet showing the name of the autrconlracuxs and state vitalist nr iut those entities have employees. if the sub-coaract rs have emniloytts,they most poi vide their weaken'urnp..policy number- I tun an employer that is providing workers'compensation insurance for my employees. Below is the policy and Job site information. Insurance Company Name:WZ7CSc\Y1 Qr1 f r pC*nlJ — Policy#or Self-its.Lie.4:wv�C3s3�JOt C Expiration�JDate: —1 Ji 1.2 Job Site Address:t1 bUrV bYCV City/StateiZip: f W're Ylc e_ %A 01 p1oZ Attach a copy of the workers'corn flan policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required wider 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 rto the Office of Investigations of the DIA for insurance coverage verification. !do hereby Rader the pains and penalties o perjure'that the information provided above is true and correct. Signature- Date: 2 Phone#: 13 "S198 Official use only. Do not write in this area.M be completed by city or town official city or Town: Permit License# Issuing Authority (circle one): I.Board of Health 2. Building Department 3.('ity,Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone 4: To:+1 41 35721 2 1 8 Page:3 of 3 2022-05-12 11:12:49 EDT 14136474046 From:Rosemary Dinatale JELLBEL-01 RDINATALE A�ORO' CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYVY) 5/12/2022 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(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 CONTACT NAME: Rosemary DiNatale HUB International New England PHONE I FAX 96 Shaker Rd (NC,No,Eat) (A/C,No): East Longmeadow,MA 01028 EDORI ss:Rosemary.dinatale@hubintemational.com t1 5 RER(a)AFFORDING COVERAGE NAIC A INSURER A;Regent Insurance Company 24449 INSURED INSURER B:Wesco Insurance Company 25011 Jelly Belly's Pools&Spas Inc. INSURER C: PO Box 936 INSURER D Westfield,MA 01086-0936 — ----- g 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 WIN 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 SUBR LTR TYPE OF INSURANCE INSD INVD POLICY NUMBER POLICY POLICY EXP IMMIDD/YYTY) IMM(OD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 l CLAIMS-MADE X OCCUR BPK00D4797-02 7/1/2021 7/1/2022 PDREM SES(Ea occurt0encel $ 100,000 MEO EXP(Any one person) $ 5,000 PERSONAL AADV INJURY E 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE E 2,000,000 X POLICY PI PE c U LOC 2,000,000 FRODUCTs.COMP/OP AGG S OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) E ANY AUTO BODILY INJURY(Per person) E OWNED SCHEDULED AUTOS ONLY AUTOS yy� BODILY INJURY(Per accidont� $ AUTOS ONLY - OS ONLYEp PROPERTY ,E $ (Per accdent?AMA E __ UMBRELLA LIAR - OCCUR EACH OCCURRENCE E EXCESS LIAR CLAIMS-MADE AGGREGATE y OED RETENTIONS 5 B WORKERS ND EMPLOYERS COMPENSATION LIABILITY Y)N X STATUTE X ERH ANY PROPRIETOR/PARTNER/EXECUTIVE WWC3535999 7/1/2021 71112022 1,000,000 0-QFICER EMBER EXCLUDED'? N N/4 E.L.EACH ACCIDENT 5 and�tory n ) E.L.DISEASE-EA EMPLOYEE S 1,000,000 Ryan.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT E 1,000,000 • DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORO 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 Christopher Garner THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 57 Dunphy Drive Florence,MA 01062 AUTHORI2ED REPRESENTATIVE I ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD I i • I ! • "9.427 4.0,0574, 46" { 1=. C2:t 144. 0 199 <., • •-z-A NIN "*"\\ \\\J • ���`YBE``y Jelly Belly's Pools & Spas u/z,_3s 1. 1-11W Inc.c 58 Southwick Rd. • P.O. Box 936 •Westfield, MA 01086-0936 • 413.568.1700 • Fax 413.572.1218 www.jeflybellyspoolsandspas.com Agreement of sale and installation between JELLY BELLY'S POOLS & SPAS INC.:A Massachusetts Corporation, (hereby designated and referred to as DEALER)and CeN1 and (hereinafter individually and collectively designated and referred to as OWNER) of(Street) a (City&State) 'UL("1'k)Ar\\ , (Business Address) F\C7`«r1 C� (Home Phone) I �3�'�•1 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. \$ X �j2 DGV3r .0Z3c \,c\sNca\\e d, \ %)c.\vi\kz.. RO,C`x.9 A 'c",cp rc,c • TOTAL FOR MATERIALS cjyQ�q SUBJECT TO ALL TERMS AND SALES TAX 3y'J VP‘ CONDITIONS ON REVERSE INSTALLATION SIDE HEREOF. LOADS OF WATER @ JELLY BELLY'S POOLS & SPAS, INC. INITIAL LINER MAINTENANCE IS NOT RESPONSIBLE FOR INJURIES BOOSTER APPLICATIONS PER YEAR DUE TO MISUSE OF POOL. TOTAL •I$L12 lla'1 NO DIVING - NO JUMPING CASH DEPOSIT 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 shall take effect as a sealed instrument ELLY BELLY'S POOLS & SPAS, INC. Signed Owner Sale Represe Ive Signed Owner JELLY BELLY'S POOLS & SPAS, INC. Date \ ‘ZZ.. By Duly Authorized Valid when countersigned by an authorized Officer of Dealer. I(Tirp Tn ntniniEo n,. - __, .