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29-614 (4) BP-2023-0333 55 STONE RIDGE DR COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 29-614-001 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-2023-0333 PERMISSION IS HEREBY GRANTED TO: Project# ABOVE POOL 2023 Contractor: License: Est. Cost: 17055 21ST CENTURY POOLS & SPAS Const.Class: Exp.Date: Use Group: Owner: GINA KROSOCZKA JARRETT J& Lot Size (sq.ft.) Zoning: WSP Applicant: 21ST CENTURY POOLS & SPAS Applicant Address Phone: Insurance: 1801 MEMORIAL DR (413)532-0100 014005032389123 CHICOPEE, MA 01020 ISSUED ON: 03/16/2023 TO PERFORM THE FOLLOWING WORK: 28 FT ROUND 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: fl Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner File #BP-2023-0333 APPLICANT/CONTACT PERSON:21 ST CENTURY POOLS & SPAS 1801 MEMORIAL DR CHICOPEE,MA 01020(413)532-0100 PROPERTY LOCATION 55 STONE RIDGE DR MAP:LOT 29-614-001 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: 28 FT ROUND POOL New Construction 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: X 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 Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits 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 5tifx‘ . `--3/) 6/0,3 Sign ture 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. i I !MAR 1 5 2023 j The Commonwealth of Massachusetts isoard of Building Regulations and Standards FOR kr).- ------1 assadhusetts State BuildingCode, MUNICIPALITY r)Ky �t ;If_om:�irispFc ic �s 780 CMR USE ' ` L'' iil(1n `li' it Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: en A 3 , 33 3 Date Applied: 11 i 1, : 'P •. f i,i V)6/()3 Building Official(Print Name) Signature D tc SECTION 1:SITE INFORMATION 1;1 5'Add'e /� 1.2 Assessors Map&Parcel Numbers oy 1.1a Is this an acceptedstreet?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 0 Private CI Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP1 2.1 Owner'of Record: Name(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg.0 Number of Units Other 1p Specify: /-2 04.0../.-eifp4 Brief Description of Proposed Work2: a t4`0,.""1 1 ors t 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 $ 0 Standard City/Town Application Fee 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: $,,,_ �(� 6.Total Project Cost: $ C S Li Check No. Check Amount: "I" Cash Amount: I� C) J 0 Paid m 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 H e Improyerent Contractor(HIC) 1\( Ca C- di _D1- S iV C QA `C '" "1 HICIRegistration_Nlumber Expiration Date Compan Name or HIC';� r.mt N ` � �Cl� c),IS \S ems^ No. treet ��� :.s c�te.� Cam• ut3 53a o16C.l Email . City/Town,�tate, 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 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. c\iL e?D^ I0 — D3 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 Massachusetts Al' 'g' DEPARTMENT OF BUILDING INSPECTIONSII 1 t z' '4 212 Main Street • Municipal Building yeti e Northampton, MA 01060 ss � � CONSTRUCTION DEBRIS AFFIDAYI (FOR ALL DEMOLITION AND RENOVATION PROJECTS) ire accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: .01 1 \C C�� The debris will be transported by: Name of Hauler: S\- Signature of Applicant: au Date: 3 " �� — 7 9. ALL INFORMATION MUST BE COMPLETED; PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION. This column to be filled in by the Building Department Existing Proposed Required by Zoning Lot size Frontage N/A N/A N/A Front: c 61w- to Setbacks: Side: lo' cc? 1 O Rear: 100' -I- l O Height % Open space: (Lot area minus bidg and paved parking) 10.Certification: I hereby certify that the information contained herein is true and accurate to the best of my knowledge. DATE:3/7 /c APPLICANT'S SIGNATURE NOTE: Issuance of a permit does not relieve an applicant's burden to comply with all zoning requirements and obtain all required permits from the Conservation Commission, Department of Public Works and other applicable permit granting authorities ACORN® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 3/7/2023 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 CONTACT NAME: ROSe Cash Dowd Agencies, LLC PHONE 14 Bobala Road (A/c.No.Ext):413-437-1061 FAx E-MAIL (A/C,No):413-437-14.61 Holyoke MA 01040 ADDRESS: rcash@dowd.com INSURER(S)AFFORDING COVERAGE NAIC# Licenser BR-1201657 INSURER A:Arbella Indemnity Insurance Company_ 10017 _ INSURED 21STCEN-01 INSURER B:Massachusetts Retail Merchants Workers' 21 st Century Solar Pools, Inc. Brian Sullivan 1801 Memorial Dr INSURER C:__ Chicopee MA 01020 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:139777916 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. WSR TYPE OF INSURANCE 1ADDL SUBR _ - POLICY EFT I POLICY EXP LTRINSD WVD POLICY NUMBER (MM/DD/YYYY) (MM!DO/YYYY) L MITS A X COMMERCIAL GENERALLIAB1IJTY Y Y 8500068379 4/1/2022 4/1/2023 EACH OCCURRENCE $1,000,000 DAMAGE TO D CLAIMS-MADE X OCCUR PREMISES(Ea occcurrence) $300,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY JPRO- ECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY Y Y 1020071994 4/1/2022 4/1/2023 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) l ANY AUTO BODILY INJURY(Per person) $20,000 OWNED X SCHEDULED BODILY INJURY(Per accident) $40,000 AUTOS ONLY AUTOS X HIRED x NON-OWNED PROPERTY DAMAGE $1,000,000 AUTOS ONLY AUTOS ONLY (Per accident) UMBRFJIALAB OCCUR EACH OCCURRENCE $ EXCESS LlAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION 014005032389123 1/1/2023 1/1/2024 PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUrnE E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Pool Sales Template CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS. Building Dept. 212 Main Street, STE 100 I AUTHORIZED REPRESENTATIVE Northampton MA 01060 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD City of Northampton CP H MTV.. S q Massachusetts ?S' S_ '<< t. A t DEPARTMENT OF BUILDING INSPECTIONS 4020:120y 212 Main Street • Municipal Building J. cam Northampton, MA 01060 317....."'N'Pf TO ACCESSORY STRUCTURE PERMIT APPLICATION (For freestanding structures 200 sq. ft. or less, at least 10 feet from any other structure) Application fee is $30 PLEASE TYPE OR PRINT ALL INFORMATION 1. Name of Applicant:s� Mtt\.‘ (DAS\-S ` � Address: DC `" f . C 'C \%C1 .Telephone: , J 5 3 d"" GI Co 2. Owner of Property: c-(('L c Y\C 4S(.1C2 C�C� Address:SS cS1171•& - t Telephone: �1 30 ' `1,'AY 3. Status of Applicant: Owner /Contractor 4. Structure Location: 55 Parcel ID:Zoning Map# Parcel # District(s) (TO BE FILLED IN BY THE BUILDING DEPARTMENT) 5. Use of Propert . Single Two Family/ Multifamily: Commercial: 6. Description of Proposed Structure: One Story Shed under 200 sq.ft.: Freestanding Deck under 200 sq.ft.,less than 30"above grade: SIZE OF STRUCTURE: Other(describe): a `� ?co \ 7. Attached Plans: Sketch Plan Site Plan Plot Plan✓ 7 8. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW YES IF YES: Has a permit been, or need to be, obtained from the Conservation Commission? Needs to be obtained Obtained , Date issued CONTINUED ON NEXT PAGE 21st Century Pools & Spas Sales Order 1801 Memorial Drive Chicopee, MA 01020 Salesperson 1: Dominic Phone: 413-532-0100 Fax: 413-532-1009 Email: brian@21stpools.com Sales Type: ABG Pool Install Web: 21 stpools.com Revenue Center: Pool sales Created: 6/18/2021 9:38:48 AM Completed: 2/6/2023 11:02:29 AM Customer Id: 3558 Invoice 3300 Register: ServiceOffice 1111111111111111111111111111111111111 1111111111111111111111111111111111111111111 JARRETT KROSOCZKA C: (617) 230-4198 55 STONE RIDGE DR Email: jarrett@studiojjk.com FLORENCE, MA 01062 OSI-ABG Pool Brian Jul 12 2021 11:OOAM Qty Part Number Description Price Amount '1 28ULTIMATE 28 R ULTIMATE POOL KIT 8,908.65 8,908.65 1 28RINST 28 ROUND ABOVE GROUND INSTALL * 5,900.00 5,900.00 1 PNCC01000E1160 100 SF CLEAN CLEAR CARTR W/1 HP OPTIFLv 703.33 703.33 PUM 1 C7100X EVO AFRAME LADDER WITH BARRIER48-54IN 256.24 256.24 POOLSGRAYCON 1 MAINTENANCE KIT MAINTENANCE KIT 66.33 66.33 1 JED171B PREMIUM VINYL LINER VAC BULK 1 25291 JUMBO THERMOMETER 1 JED5056016 PRO 8FT-16FT TEL POLE 1 JED364 SKIMMER HEAD HEAVY DUTY PLASTIC FRAME 1 145145 STANDARD LEAF RAKE ALUMINUM 1 23060610 ALGAE ALL 601 QT 1 22947B10 SMART SHOCK 1 LB 1 22947610 SMART SHOCK 1 LB 1 25918B10 DELUXE VAC HOSE 1-1/2IN 30FT 3 0.00 .00 1 JOB/LABOR JOB/LABOR * 600.00 600.00 charge for mini excavator to remove rock and stump *Non-Taxable Items Sub Total $16,434.55 State Tax $620.91 City/County Tax $0.00 Total $17,055.46 Amount Paid $2,611.00 Balance $14,444.46 Payments Type Approval Code Id Numbers Amount Date of Trans Type Reference# Date Received Employee Name Visa 02505d $2,611.00 6/18/2021 P 33 6/18/2021 Dominic Santos invoice: 3300 JARRETT KROSOCZKA Tuesday,March 7,2023 Page 1 of 29-598-001 29-610-001 2.391 17 29-484-001 130 76 29-599-001 P Swi 29 409-001 1.973 3. 29-600-001 1.96 29-609401 0 1.919 Z d;° m ploki feet I Set °‘Q �. ?� 2s-sot•001 t re L 2 16 110 29-1�4-001 IA r m ,�45 21 fet rya 'tom 29-602-001 - 1.93 29409401 70 1.99 , 93 29.48 '01 130. 29 405.001 29-603401 tar1.90E 7? So,rces:Esri,HERE,Garmin,Intermap,increment P Corp,GEBCCr4l, O.<HPS.NRCAN,Geo8ase,IGN,Kadester tJ.. Crnraroe Survey.Esri Japan.METI,Esri Coins tHong Kong).to)OpenStreetMapsplr8 ulors,and the GIS User Community.Tiplrea Ecra 88 .SHA Krosoczka Plot Y° l., The information depicted on this map is for planning purposes only. • 4 3/8/2022 10:17:01 AM -�,_ It is not adequate for legal boundary definition,regulatory • interpretation,or parcel-level analyses. Scale: 1 n=95' r' �� Scale is approximate "= `� The Commonwealth of Massachusetts • l ./, Department of Industrial Accidents ez= 1 Congress Street, Suite 100 = t•i Boston,MA 02114-2017 ' .4 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information c Please Print Legibly Name (Business/Organization/Individual):al �1 alZ�(V \ C�1 S ,L. Address: \' \ ���1(V\�f�t K\ .`r...>r (� City/State/Zip: Phone#: Are ysu an employer?Check the appropriate box: I�Jt/ Type of project(required): 1. I am a employer with I S employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition 10❑Building addition 4.0 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 1 L❑Electrical repairs or additions proprietors with no employees. 12.❑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.: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other�^ 152,§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. :Contractors 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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. � Insurance Company Name: �- „...--(k ,e- Policy#or Self-ins.Lic.#:6 k tic.,tic.,d'Q,3'a 3 g°1 i Expiration Date: 1( I /90 a Job Site Address:D`‘ S tQ—0( Pet A h City/State/Zip: (n- ' S G i o& a---- Attach a copy of the workers'compensation policy declaration age(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. Signature: Date: — 1—a-3 Phone#: (-f I b 3 Cs I G C) Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# 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#: