Fillable Pool Permit Application (Town of Hopedale)

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Pool Permit Application (Town of Hopedale)

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TOWN OF HOPEDALE
78 Hopedale Street - P.O. Box 7
Hopedale, Massachusetts 01747
Tel: 508-634-2203 x216 Fax: 508-634-2200
Office of:
Building Department
APPLICATION FOR POOL PERMIT
To the Building Commissioner: Date: __________________
The undersigned hereby applies for a permit to install a pool according to the following information and plans herewith:
LOCATION: _________________________________________ ASSESSORS’ MAP: _______ Parcel: ________
OWNERS’S NAME: ______________________________ ADDRESS: _________________________________
OWNER’S PHONE: __________________________________
INSTALLER’S NAME: _______________________________ ADDRESSS: ________________________________
INSTALLER’S PHONE: _____________________________ Inground Pool Only) HIC. # _______________________
(Submit Copy)
INGROUND: _________ ABOVE GROUND: _________
IS ANY PART OF THIS PROJECT WITHIN 100’ OF A WETLAND? YES ___ NO_____ (If unsure, check with
Conservation commission)
SIZE OF PROPOSED POOL: __________ EST. COST OF CONSTRUCT ON (excluding land) _______________
DESCRIPTION OF PROJECT____________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
I hereby certify that I am the owner of record of the property listed above or that I have been duly authorized by said owner to make
the application as the owner’s agent and that all the information above, and plans and specifications submitted are correct and that all
work pursuant thereto shall comply with all applicable provisions of the Commonwealth of Massachusetts Statues, Building Code, and
Town of Hopedale Zoning By-Laws shall be complied with. The following is subscribed to and executed by me under the Pains and
Penalties of Perjury.
OWNERS SIGNATURE: _________________________________________ DATE: ________________________
INSTALLER’S SIGNATURE: _____________________________________ DATE: ________________________
PERMIT#______________________________ FEE $________________________________
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AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation ("OCABR") regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing
work on such homes, a contractor must be registered as a Home Improvement Contractor ("HIC").
M.G.L. Chapter 142A requires that the "reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pre-existing owner- occupied building
containing at least one but not more than four dwelling units. ... or to structures which are adjacent to such residence
or building" be done by registered contractors.
Note: If the homeowner contracted with a corporation or LLC, that entity must be registered.
Type of Work: ____________________________________________ Est. Cost: ____________
Address of Work: _______________________________________________________________
Owner Name: __________________________________________________________________
Date of Permit Application: _______________________
I hereby certify that:
Registration is not required for the following reason(s):
____ Work excluded by law (explain) _______________________________________________
____ Job under $1,000.00
____ Building not owner-occupied
____ Owner pulling own permit (explain) ___________________________________________
____ Other (specify) ____________________________________________________________
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH
UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME
IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE
ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L. Chapter 142A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
______________ _____________________________________________________________________________
Date Contractor Name/Signature HIC Registration No.
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property:
_________________________________________________________________________
Date Owner Name/Signature
TOWN OF HOPEDALE
78 Hopedale Street - P.O. Box 7
Hopedale, Massachusetts 01747
Tel: 508-634-2203 x216 Fax: 508-634-2200
Office of:
Building Department
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Lafayette City Center
2 Avenue de Lafayette, Boston, MA 02111-1750
www.mass.gov/dia
Workers’ Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):_________________________________________________ _
Address:__________________________________________________________________________
City/State/Zip:_____________________________ Phone #:________________________________
*Any applicant that checks box #1 must also fill out the section below showing their workers’ compensation policy information.
†
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:____________________________________________________________________________
Policy # or Self-ins. Lic. #:__________________________________________ Expiration Date:____________________
Job Site Address: City/State/Zip:______________________
Attach a copy of the workers’ compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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:
Phone #:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: ___________________________________ Permit/License #_________________________________
Issuing Authority (check o
ne):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing
Inspector 6. Other ______________________________
Contact Person:______________
___________________________ Phone #:_________________________________
Type of project (required):
6. New construction
7. Remodeling
8. Demolition
9. Building addition
10. Electrical repairs or additions
11. Plumbing repairs or additions
12. Roof repairs
13. Other____________________
1. I am a employer with _________
employees (full and/or part-time).*
2. I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers’ comp. insurance
required.]
3. I am a homeowner doing all work
myself. [No workers’ comp.
insurance required.]
†
Are you an employer? Check the appropriate box:
4. I am a general contractor and I
have hired the sub-contractors
listed on the attached sheet.
These sub-contractors have
employees and have workers’
comp. insurance.
‡
5. We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, §1(4), and we have no
employees. [No workers’
comp. insurance required.]
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Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers’ compensation for their employees.
Pursuant to this statute, an employee is defined as “...every person in the service of another under any contract of hire,
express or implied, oral or written.”
An employer is defined as “an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.”
MGL chapter 152, §25C(6) also states that “every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required.”
Additionally, MGL chapter 152, §25C(7) states “Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority.”
Applicants
Please fill out the workers’ compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers’ compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers’
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under “Job Site Address” the applicant should write “all locations in ______(city or
town).” A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department’s address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Lafayette City Center, 2 Avenue de Lafayette
Boston, MA 02111-1750
Tel. (617) 727-4900 or 1-877-MASSAFE
Fax (617) 727-7749
www.mass.gov/dia
Revised 7-2019
TOWN OF HOPEDALE
MASSACHUSETTS
Hopedale Town Hall Building Dept.
P. O. Box 7 (508) 634-2203 x216
Hopedale, MA 01747
POOL GUIDELINES
1. A permit is required if the pool is going to be made more than 24 inches deep or
more than 250 square feet and equipped with a permanent water re-circulating
system.
2. Any in-ground swimming pool located in the Town of Hopedale shall be enclosed
by a fence or other suitable barrier, at least four (4) feet high. Entrance to the pool
shall be though doors or gates capable of being locked when the pool is not in use.
“Suitable” shall be up the discretion of the Building Commissioner.
3. Any above ground swimming pool located in the Town of Hopedale, which is nor
fenced in shall provide a means, approved by the Building Commissioner, whereby
ladders, stairs or other means of entrance are raised, removed or locked when the
pool is not in use.
4. Any gates shall be self-latching and shall be equipped to accommodate a locking
device.
5. The owner of the real estate, in which the pool is located, shall be responsible for
compliance with these requirements and subject to the penalties for any violations.
6. No pool will be allowed to be located in the front yard area.
7. No pool will be allowed to be located less than 10 feet from the side and rear of the
property lines.
8. The Building Commissioner reserves the right to require a proposed plot plan
prepared by a “Massachusetts Registered Surveyor” if in his opinion deems it
necessary.
9. In order to obtain a building permit, the following must be done.
a. Fill out building permit application
b. Fill out electrical application
c. Fill out gas permit application/if pool is to be heated.
10. Once a building permit is issued, you may begin the construction of the pool. Keep
the building permit on the property. Inspections are required, and inspectors are
required to sign the building card.
11. Above Ground Pool: Required Inspections
No above ground pool shall be filled with water until the electrical and plumbing
inspectors have inspected and signed the building permit card.
a. Electrical Inspector- Joe Scanzaroli (508) 954-5550
b. Gas Inspector- John Fontana (508) 473-1100
After the above is completed, call the Building Department for a final inspection.
12. In-ground Pool: Required Inspections
An excavation inspection shall be required for an in-ground pool.
No in-ground pool shall be filled with water until the electrical and plumbing
inspectors have signed the building permit card.
a. Electrical Inspector- Joe Scanzaroli (508) 954-5550
b. Gas Inspector- John Fontana (508) 473-1100
13. A permanent fence is required for final inspection.
After the above is completed, call the Building Department for a final inspection.
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Pool Permit Application (Town of Hopedale)

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Completed 14 July 2020

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