Fillable Swimming Pool Permit (Town of Westminster, Massachusetts)

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Swimming Pool Permit (Town of Westminster, Massachusetts)

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BROWSE TOWN OF WESTMINSTER, MASSACHUSETTS (MA) FORMS

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PLEASE READ THE
IMPORTANT INFORMATION FIRST!
Happy & Safe Swimming !!
SWIMMING POOLS INFO
Pools need a Building Permit and a Wiring Permit. (the wiring permit is so that the pool will be
wired to a ground-fault outlet.)
The permit must be filled out with the Owners information and the Builder’s full information
including licenses and insurance liabilities. Type of pool (above or in-ground), dimensions of the
pool (NOT the square footage), estimated value of work, signature by both owner & builder or a
copy of the signed contract.
Information required with the application:
Manufacturer’s/Contractor’s specifications on the pool construction and filter information.
Specifications or plans for fence or enclosure required by Mass. State Building Code, Section 120.M
Plot plan indicating the location of the pool, showing the distances from the lot line. (15’ side
setback, 20’ rear setback and depending on the zone it’s located in either 25’ or 30’ from the front
lot line.)
The application must be approved by:
1. Assessor’s Office: to obtain the Map and Parcel numbers
2. Treasurer’s Office
3. Board of Health: they will require information on the distance from the pool to the septic system.
4. Conservation Commission: if the pool will be located within 100 ft. from ANY wetland (this
includes lakes, ponds, rivers, streams, seasonal wet areas, etc.) If there are any doubts, the owner
should give the name of the Con Comm representative in that area to assure compliance.
5. Building/Zoning: approval of plans and plot plan.
When your building permit is approved, processed and printed. You will be called to pick it up and
it must be displayed visibly on the property while construction is being done.
Please make sure that you have a licensed electrician do the wiring of the pool. The electrician
must apply for the Wiring Permit separately. Once that is completed, please call the Wiring
Inspector for an inspection. Harry Parviainen 774-764-1006
Once the pool walls are erected; when the water is in the pool and the filter and pump are working
and the fence is installed. Please call the Building Commissioner for the final inspection. 978-874-
7407. A temporary fence is required until there is water in the pool. Occupancy or use of the pool
is not allowed until the permanent fence is erected and inspection is completed.
Building Permit:
Wiring Permit:
In-Ground……………$100.00
In-Ground……………$75.00
Above-Ground………$50.00
Above-Ground………$50.00
TOWN OF WESTMINSTER
NAME OF OWNER
DATE
PERMIT #
ADDRESS OF OWNER
TELEPHONE
IF IN A SUBDIVISION - NAME
LOT NO.
SIDE OF STREET
NORTH SOUTH EAST WEST
MAP #
PARCEL #
SIZE OF
LOT
SQ. FT.
ACRES
ZONING
PURCHASED PROPERTY FROM
DATE
LAND AREA DISTURBANCE 10,000 SF TO 1 ACRE (43,560 SF) LID REGULATIONS = CONSERVATION AGENT
OVER 1 ACRE (43,560 SF) STORM WATER MANAGEMENT = PLANNING BOARD
BUILDER’S NAME
TELEPHONE
BUILDER’S ADDRESS
LICENSE #
HIC #
EMAIL ADDRESS:
PURPOSE OF NEW BUILDING OR ALTERATION
SQ. FT. AREA
IS THERE PLUMBING, HEATING, ELECTRICAL OR SHEET
METAL ASSOCIATED WITH THIS CONSTRUCTION?
PLUMBING HEATING ELECTRICAL SHEET METAL NONE
OVERALL DIMENSIONS OF BUILDING
NO. OF STORIES
NO. OF ROOMS
NO. OF FAMILY
UNITS
IS SEWERAGE SYSTEM TO BE:
CONSTRUCTED REPAIRED ALTERED
NO. OF
BEDROOMS
NO. OF
BATHROOMS
NO. OF
LAVATORIES
NO. OF GARBAGE
DISPOSAL UNITS
WATER SUPPLY
TOWN WATER NEW WELL EXISTING WELL
TYPE OF CONSTRUCTION
FOUNDATION MATERIAL
TYPE OF HEATING SYSTEM
NO. OF
FIREPLACES
GARAGE SEPARATE
ATTACHED IN BASEMENT
GARAGE
SQ. FT.
NO. OF VEHICLES
ESTIMATE OR
CONTRACT COST
APPROVED BY ZONING
DATE
PERMIT FEE
APPROVED BY BOARD OF HEALTH
DATE
APPROVED BY PLANNING BOARD
DATE
APPROVED BY CONSERVATION COMM
DATE
APPROVED BY FIRE CHIEF
DATE
APPROVED BY HIGHWAY DEPARTMENT
DATE
APPROVED BY BUILDING INSPECTOR
DATE
APPROVED BY TREASURER/COLLECTOR
DATE
The Commonwealth of Massachusetts
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Dwelling
FOR
MUNICIPALITY
USE
Revised Mar 2011
This Section For Official Use Only
Building Permit Number: _____________________ Date Applied: ______________________________
___________________________________ ____________________________________________ ___________
Building Official (Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address:
____________________________________________
1.1a Is this an accepted street? yes_____ no_____
1.2 Assessors Map & Parcel Numbers
_____________________ ____________________
Map Number Parcel Number
1.3 Zoning Information:
_______________ ___________________
Zoning District Proposed Use
1.4 Property Dimensions:
_____________________ ____________________
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 Suppl
y
: (M.G.L c. 40,
§
54)
Public Private
1.7 Flood Zone Information:
Zone: ___ Outside Flood Zone?
Check if yes
1.8 Sewage Disposal System:
Municipal On site disposal system
SECTION 2: PROPERTY OWNERSHIP
1
2.1 Owner
1
of Record:
________________________________________ _________________________________________________
Name (Print) City, State, ZIP
_____________________________________________ _________________ ___________________________________
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK
2
(check all that apply)
New Construction Existing Building Owner-Occupied Repairs(s) Alteration(s) Addition
Demolition Accessory Bldg. Number of Units_____ Other Specify:________________________
Brief Description of Proposed Work
2
:_________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:
(Labor and Materials)
Official Use Only
1. Building $
1. Building Permit Fee: $_______ Indicate how fee is determined:
Standard City/Town Application Fee
Total Project Cost
3
(Item 6) x multiplier _______ x _______
2. Other Fees: $_________
List:_________________________________________________
____________________________________________________
Total All Fees: $_______________
Check No. ______Check Amount: _______Cash Amount:______
Paid in Full Outstanding Balance Due:_____
_
____
2. Electrical $
3. Plumbing $
4. Mechanical (HVAC) $
5. Mechanical (Fire
Suppression)
$
6. Total Project Cost:
$
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL)
________________________________________________________
Name of CSL Holder
_________________________________________________________
No. and Street
_________________________________________________________
City/Town, State, ZIP
_________________________________________________________
_
_________________ ______________________________________
Telephone Email address
_____________________ ______________
License Number Expiration Date
List CSL Type (see below) _______________
Type Description
U Unrestricted (Buildings up to 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
D Demolition
5.2 Registered Home Improvement Contractor (HIC)
______________________________________________________________
HIC Company Name or HIC Registrant Name
______________________________________________________________
No. and Street
________________________________________ ____________________
City/Town, State, ZIP Telephone
_____________________ ______________
HIC Registration Number Expiration Date
_______________________________________
Email address
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
1
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”
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers’ Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
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 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:
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 (circle one):
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):
7. New construction
8. Remodeling
9. Demolition
10 Building addition
11. Electrical repairs or additions
12. Plumbing repairs or additions
13. Roof repairs
14. Other____________________
1. I am a employer with _________employees (full and/or part-time).*
2. I am a sole proprietor or partnership 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.]
†
4. 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
proprietors with no employees.
5. 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.
‡
6. 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.]
Are you an employer? Check the appropriate box:
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 Department’s address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
Revised 02-23-15
TOWN OF WESTMINSTER
Building Department
11 South Street
Westminster, MA 01473
Paul R. Blanchard, CBC Phone: 978-874-7407
Building Commissioner Fax: 978-874-7462
Email: pblanchard@westminster-ma.gov
In accordance with the provisions of MGL c 40, S 54, a condition
of the Building Permit is that the debris resulting from this work shall
be disposed of in a properly licensed solid waste disposal facility as
defined by MGL c 111, S 150A.
The debris will be disposed of in:
________________________________________________
(Location of Facility)
_______________________________________
Signature of Permit Applicant
________________________________
Date
ww:debris
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Swimming Pool Permit (Town of Westminster, Massachusetts)

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Completed 17 July 2020

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