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30C-067 09 t 1 990 tbO 0£, £8'691 917'68 T 091 60 60'1.9E EZO'OE 6 ZL`1:° �, � t 00'09 L90 ° 00E c21 LO 'L k ,---------------- \ 1 z; ti9 • • ■ 586 • o$ r s 4 ,.., 7 :; ' - ,, ../i. ' -/ 4 / F o r d , _ / = = = - ›,,/. , . .. : ' ":#:' ' ..„,..,.._ * / _ ,,,-- -c ,,==. „=4- _,'\,,=,,,,---- / , , : =F " • • • ti --6704i—uvecta c Office of Consumer Affairs and usiness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 159772 Type: Ltd Liability Corporation Expiration: 5/27/2012 Tr# 296849 HOMETOWN STRUCTURES ANDREW KURTZ 627 SOUTHAMPTON RD WESTFIELD, MA 01085 Update Address and return card. Mark reason for change. El Address El Renewal El Employment 0 Lost Card DPS -CA1 Co 50M- 04/04- G101216 ✓/.e & cweal!% 7CassacAuJel License or registration valid for individul use only Office of Consumer Affairs & Business Regulation g y / HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: '' Registration: 159772 Type: Office of Consumer Affairs and Business Regulation .„\ 11 10 Park Plaza - Suite 5170 Expiration: 5/27/2012 Ltd Liability Corporate Boston, MA 02116 HOMETOWN STRUCTURES ANDREW KURTZ 627 SOUTHAMPTON RD WESTFIELD, MA 01085 Undersecretary Not valid without signature • • Board of Building Regulatiogs and Standards Construction Supervisor License License: CS 98186 Expiration: 8/3/2011 Tr# 98186 Restriction: 00 ANDREW KURTZ 295 BROMLEY RD HUNTINGTON, MA 01050 Commissioner 00 - 35,000 cf enclosed space IA - Masonry only 1G - 1 2 Family Homes Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. 30 -year architectural 2 x 6 rafters 16" on shingles over 1/2" CDX center with collar plywood roof sheeting ties 4 center �� �� �; ridge on vent E exclusive detailing, v ' '''' ' ,go , A 100- I with large roof overhang = \ : ‘.„4„ 1 4 ..44,4 F.,;01. , , i Ak '‘. d x } .: v F double 2 x 6 header over windows and doors pre ssure treated floor system, 4 x 4 rails, joists 12 on center, 5/8 plywood vinyl over 1/2 CDX p lywoo d _:0 ' . • The Commonwealth of Massachusetts -2 ° -= Department of Industrial Accidents ++- -- _, Office o f Investigations t ` '' ? '} 600 Washington Street • �r Boston, MA 021II vA= www.massgov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): H o e ko t.0 n S tr,t:,turt' Address: C.7 Sov tkawlp lbn RA Cit /State /Zip: •esf It cJ MR 0105 Phone #: Li I 3 512 7170 Are you an employer? Check the appropriate box: i y I am a employer with 8 4. © I am a general contractor and I Typ of project (required): employees (full and/or part-time).* have hired the sub - contractors 6. New construction 2. Q I am a sole proprietor or partner- listed on the attached sheet. • 7. 0 Remodeling ship and have no employees These sub - contractors have 8. Q Demolition working for me in any capacity. employees and have workers' 9. Q Building addition [No workers' comp. insurance comp. insmance.t required] 5. 0 We are a corporation and its 10.[] Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no 13. Other a cc e�3a r 6t�3 employees. [No workers' y 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 Compan_yName: eer• k5ktr e In 5 ( cal ce Lamp any Policy # or Self -ins. Lic. #: w C 00 to - y F- 95? Expiration Date: 5 / c2"7J p 01 ! Job Site Address: .5 y C kyvo f 3-1., City /State /Zip: Fforcrt (. /r)lq 0/0 (c J 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. . Si_ .true: It s....... .. • "_r Date: ^ 1 /U / Phone #: 413 5G ) 7171 ' 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 . lI Contact Person :. Phone #: ISSUED BY THE STOCK INSURANCE COMPANY HEREIN CALLED THE COMPANY AGENT NUMBER POLICY NUMBER GRANITE STATE INSURANCE COMPANY 0094075 -00 WC 006 -48 -4502 13102 013 -66- 0510 -00 INCORPORATED UNDER THE LAWS OF ■ ITEM 1. NAMED INSURED: MAILING ADDRESS IDENTIFICATION NO.: ANDREW KURTZ & JOHN KURTZ & JOSEPH KURTZ C H A R T I S 627 SOUTHAMPTON ROAD WESTFIELD, MA 01085 -0000 A Chartis company EXECUTIVE OFFICES: SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 175 Water Street New York, NY 10038 I.D# MA Ul #: PRODUCERS NAME AND ADDRESS BERKSHIRE INSURANCE GROUP INC. WORKERS COMPENSATION AND EMPLOYERS 138 LONGMEADOW STREET LIABILITY POLICY INFORMATION PAGE LONGMEADOW„ MA 01106-0000 INSURED IS PREVIOUS POUCY NUMBER PARTNERSHIP RENEWAL 007435010 OTHER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 ITEM 2 POLICY PERIOD 12:01 A.M. standard time at the insureds mailing address FROM 05/27/10 TO 05/27/11 ITEM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item 3.A. • The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ ;00.000 policy limit Bodily Injury by Disease $ 100.000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE ENDORSEMENT - WC200306A D. This policy includes these SEE EXTENSION OF ITEM 3.D. OF THE INFORMATION PAGE - WC990612 ITEM 4 The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Estimated Total Rate Per Estimated Classifications Code Number Remuneration $100 OF Re. Premium © Annual ❑ 3 Year muneration © Annual ❑ 3 Year SEE EXTENSION OF ITEM 4. OF THE INFORMATION PAGE - WC7754 TAXES /ASSESSMENTS /SURCHARGES $476 EXPENSE CONSTANT (EXCEPT WHERE APPLICABLE BY STATE) $ 338 MA MINIMUM PREMIUM $ 500 MA TOTAL ESTIMATED PREMIUM $8,240 If indicated below. interim adjustments of premium shall be made: El Semi - Annually 0 Quarterly 0 Monthly DEPOSIT PREMIUM 06/11/10 ASSIGNED RISK 66 (� Issue Date Issuing Office Authorized Representative wC 00 00 01 39967 (Rev'd 04/08) • HOMETOWN STRUCTURES INVOICE 627 SOUTHAMPTON ROAD I; ' - WESTFIELD, MA 01085 -1329 Order Date c5 S - / 413 - 562 -7171 = `"r nL.,,,,..„( Estimated Delivery Date d Lks BILL TO: T.. 1� �1 . Si-. e NOTES: • ADDRESS: S y C1epw+ V' Q� Fl 0 re" (Q., M A O 0/bD PHONE # SV y 7 6 ' S CELL PHONE # 0 3 Yo email address 54; bor- J u ck e (y1 5n. C.o!Y7 ❑ DuraTemp T1 -11 ❑ XVinyl l 1 Instock Display Shed ❑ To Be Custom Built Body Color: Body Color: (- r K Delivered Fully Assembled Corner & Fascia Color: Corner Color: Wk;1 <- Door Color: Door Color: L A- :4 ❑ Built on site SOFFIT CHOICE: (For New England Sheds Only) Solid T1 -11 ❑ Body color SOFFIT CHOICE: (For New England Sheds Only) Size: 1 b X I 8. Exposed rafter tails ❑ Body color Style: Aluminum Strip vent o White O Brown Perforated vinyl )(White ❑ Brown Perforated vinyl White Brown Beaded vinyl ❑ White only ❑ Gambrel Beaded vinyl ❑ White only ❑ Cape ❑ NE Cape ❑ Ranch ❑ NE Ranch Single Door Double Door ❑ Quaker ❑ NE Quaker 3' F-13 / ' F - 0 Base Price $ ❑ Villa ❑ NE Villa Width &Type: lo ❑ Dutch Colonial ❑ NE Dutch Colonial e 0. o — 3 00 ❑ NE Chalet Window Price $ Transom Frame ❑ W ❑ B ❑ W ❑ B )(NE Victorian Door Price $ 0 ❑ NE Sugar Shack Hinges KStd ❑ Strap ❑ Std ❑ Strap Soffit Price $ 1) ❑ NE Swiss Chalet - ❑ with dormer Ramp: XI 6 x 4 ❑ with upper level ❑ 5 x 4 ❑ NE Homesteader ❑ 54 x 4 ❑ Other x $ 0 Loft: ❑ 4 x 8 Shingles: Window Type ❑ 4 x 10 ❑ Dual Black ❑ 18 x 36 ❑ 6 x 12 ❑ Other x $ ❑ Earthtone Cedar ❑ 24 x 36 Flower boxes: ❑ Wood ❑ 18 ❑ Dual Gray a 7'36 x 36 _ ($I 'Vinyl 0 2 C� Dual Brown _ ❑ ventilator Color 1- C'36 $ eathetwood ❑ Harvard Slate Shutters: ❑ Wood ❑ Charcoal Gray _ ❑ Color tsC lirVinyl $ 0 Drip Edge: AIN ❑B Frames: J"w ❑e $ K Site Preparation - pad size 13 x 1 $ 75S Nr subject to site evaluation ttp ' Overwidth road permit fee $ YO M • 3975 t Sub Total $ l Load Door Towards: Sales tax: $ 19 l'• . 7S r ❑ Front ❑ Driver s Side TOTAL: $ 1 i 73.75 5 ' , 1 1 ' '3' ❑ Back ❑ Passenger s side Deposit: $ I f l 7 3 .75 "� t ^ BALANCE: $ • r . SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor (CSL) /8 - 3 do // _PD are t.,,) X. r l2 License Number Expiration Date Name of CSL - Hol r 1,) p ci s o roreA7 /) J` �,�� yn , Mg List CSL Type (see below) Address Type Description U Unrestricted (up to 35,000 Cu. Ft.) Signature R Restricted l &2 Family Dwelling .SGs,' 2i7/ M Masonry Only RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Reg'stered Home Improvement Contractor (HIC) HIC Company Name or HIC Registrant Name Registration Number G$,) RA, Wh, i la , g o/oa' Address 5 ` ? 7 - - .70)3 SL d- Expiration Date Signature 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, / r c . k � e� , as Owner of the subject property hereby authorize o ,7•e - 6... n SiyV J '-' to act on my behalf, in all matters relate e to work authorizes ,y ,400 . building permit application. Signature of Owne Date SECTION 7b: OWNER OR AUTHORIZED AGENT DECLARATION I, G " /1 Y tt+T' ✓1 , as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and behalf. 4, ,, At , Print Nam 7- 70 Signature of Owner or Authorized Agent Date (Signed under the pains and penalties of perjury) 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 and Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.R6 and 110.R5, respectively. 2. When substantial work is planned, provide the information below: Total floors 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 1 Board of Building Regulations and Standards FOR MUNICIPALITY ��; Massachusetts State Building Code, 7${}C'Ibf T " "'� USE Building Permit Application To Construct, Repair,ik- : - th` ft 'uu ■ . Revised January One- or Two - Family Dweaing 1, 2008 This Section For Official Lase OnlAUG _ 5 2010 Building Permit Number: Date Ap I f Signature: I CF r'. 1 � .7 7„ T ' `:vS Building Commissioner/ Inspector of Buildings 1 Date _ - -- SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map & Parcel Numbers S y C iernzn,. 54, F or vI ct mg ofow 1.1a Is this an accepted street? yes k no Map Number Parcel Number 1.3 Zoning Information: 1.4 ro erty Dimensions: 1. .5 nc,cs , - r 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 ,2o0' -t-/ L rove /R ; Ioo , /O(' -F 1.6 Water Supply: (M.C.L c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Private ❑ Zone: _ Outside Flood Zone? Municipal On site disposal system ❑ n V Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner' of Record: T. M. S . Lel ence.. y Ct n-i- V. F /. /nA 0/062 Na se (Print/ .-- Address for Service: ign. ure Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction ❑ Existing Building ❑ Owner- Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. IV Number of Units Other ❑ Specify: Brief Description of Proposed Work 42. I &A ---ry o 1 p t - Oil .-si b Lte 454'e` et c.ersa 6 m 10It /8 SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 3 / 3 1. Building Permit Fee: $ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2. Electrical $ 3 1:1 Total Project Cost (Item 6) x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ 3 / Check No. Check Amount: Cash Amount: / 6. Total Project Cost: $ ❑ Paid in Full ❑ Outstanding Balance Due: * 17C Z; ,d° k File # BP- 2011 -0103 APPLICANT /CONTACT PERSON KRAWCZYK BERTHA M & TERESA M ST LAURENCE ADDRESS/PHONE 54 CLEMENT ST FLORENCE PROPERTY LOCATION 54 CLEMENT ST MAP 30C PARCEL 067 001 ZONE SR(100) //WP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT `ee ai B. . ermitF' - • out - ypeo Construction: Shed New Construction Non Structural interior 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 INFOOIATION PRESENTED: Y/ pproved 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 -�-� -` / 8/12/10 Signature of Building Officia 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. `, ,ENT "T ' BP- 2011 -0103 GIS #: COMMONWEALTH OF MASSACHUSETTS p :Block: 30C - 067 if CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2011 -0103 Project # JS- 2011- 000188 Est. Cost: $3180.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOMETOWN STRUCTURES 98186 Lot Size(sq. ft.): 63597.60 Owner: KRAWCZYK BERTHA M & TERESA M ST LAURENCE Zoning: SR(100) / /WP Applicant: KRAWCZYK BERTHA M & TERESA M ST LAURENCE AT: 54 CLEMENT ST Applicant Address: Phone: Insurance: 54 CLEMENT ST (413) 584 -7185 0 WC FLORENCEMA01062 ISSUED ON ::8/17/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: ERECT 10 X 18 SHED 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: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 8/17/2010 0:00:00 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner