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35-067 (3) 30-year 2 x 6 rafters 16" on 0 -yea r a rchitectura l shingles over 1/2" CDX center with collar plywood roof sheeting 44 t „. z. ties 4' on center ridge vent U exclusive detailing, ' with large roof overhang - . M Y a a .� ti#4. ii i ' ''' . 7 ,-. ' N ' 1 - - ' - „ i 4. -: , , 7,, - '''''' ,..iito i A double 2 x 6 header over windows and doors pre � treated floor 3 system, 4 x 4 rails, joists 12" ,, °' on center, 5/8" plywood vinyl over 1/2 CDX plywood ti r /fir t (Jr,rrr( reir'w ;ei //l ( 74i.;. (te ti.ie //.i Office of Consumer Affairs and Business Regulation x t, 10 Park Plaza - Suite 5 170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration. 159772 Type: Ltd Liability Corporation Expiration: 5/27/2014 TO 228578 HOMETOWN STRUCTURES ANDREW KURTZ 627 SOUTHAMPTON RD WESTFIELD, MA 01085 update Address and return card. Mark reason for change. Address Renewal Employment Lost Card . . • • • • Massachusetts - Department of Public Safct • Board of Building Regulations and Standards Construction Supervisor License • License: CS 98186 • ANDREW KURTZ 295 BROMLEY RD HUNTINGTON, MA 01050 Expiration: 8/3/2013 tilVr Tr#: 20132 • c eoitviiwitivecta yty,/,(mocidaeleal. 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 • date Address and return card. Mark reason for change. Al ss Renewal I ' Employment Lost Card oPs-cm 0 50M-04/04-G101216 NOTICE NOTICE TO TO EMPLOYEES EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 - http://www.mass.govidia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 30, this will give you notice that I (we) have provided for payment to our injured employees under the above-mentioned chapter by insuring with: Technology Insurance Company NAME OF INSURANCE COMPANY 5800 Lombardo Center Cleveland OH 44131-2550 ADDRESS OF INSURANCE COMPANY TVVC3321269 5/27/2012 to 5/27/2013 POLICY NUMBER EFFECTIVE DATES Berkshire Insurance Group, Inc. PO Box 4889 Pittsfield MA 01202 413 NA ME OF INSURANCE AGENT ADDRESS PHONE # Hometown Structures, LLC 627 Southampton Road Westfield MA 01085 EMPLOYER ADDRESS EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER City of Northampton • • 4fIrti4 Massachusetts � ; snt DEPARTMENT OF BUILDING INSPECTIONS b , , `° 212 Main Street • Municipal Building vy �� Northampton, MA 01060 INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his /her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he /she resides or intends to be, a one or two family dwelling, attached or detached structures accessory to such use and /or farm structures. A person who constructs more than one home in a two- year period shall not be considered a home owner." The building department for the City of Northampton wants any person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation /footings (before backfill), sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, understand the above. (Home owner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location • The Commonwealth of Massachusetts "---- Department of Industrial Accidents `` f Office of Investigations 600 Washington Street 411 41011V Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name (Business /Organization/Individual): +c [ Q"i-e) 34-(..)c ■,res _ Address: a 1 S a,4} k on4o,-. City /State /Zip: Les e) c, y"' P 0/o '.S Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. I ar: ^ employer -with / © 4. n I am a general contractor and I r, New « �ui r 6. U bl construction employees (full and/or part- time).* have hired the sub - contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. El Remodeling ship and have no employees These sub - contractors have 8. II] Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance. required.] 5. n We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.n Other ccr�5 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. l Insurance Company Name: �trk -S, .1-11 -56r Policy # or Self -ins. Lic. #: T C. 3 3 07 Expiration Date: 5 ' ? � 7 9X1 Job Site Address: $ I R ? an vacs City/State /Zip: Po rcn ce._, (1 d/O to) 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: / y Date: — $ Sgnature: � -_ �� Phone #: / / 3— S(o a )-7 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other • Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : A n 4 re w �"� Z C S c /8 (, License Number .255" ry M 1� y / n1i ice., (1 Q f 0S b - 3 d G i 3 Address Expiration Date I 1, - St - Signature Telephone 9. Realstered Home improvement Contractor: Not Applicable ❑ .i S INZ=' r-cS S 9 - 7 _) Company Name Registration Number Address 1 n /y Expiration Date W o_5 4 A I ' I (-))6 Telephone S(D) - 277/ SECTION 10- 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 I No ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two - year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) • • • New House Addition Replacemenlindows Alteration(s) Roofing Or Doors 0 0 Accessory Bldg. Demolition New Signs [ I Decks [ ] Siding [ ] Other [ ] Brief Description of Proposed Work: t\EL L J 3 c. r c I X a G C u r •S Alteration of existing bedroom Yes No Adding new bedroom Yes )C No Attached Narrative Renovating unfinished basement Yes )C No Plans Attached Roll - Sheet 6a. If New.h use and or addition to existing housing, complete the following: a. Use of building':One Family Two Family Other b. Number of rooms in each-family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No Is construction. within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT c+,' Q P4 a ryl S , as Owner of the subject property hereby authorize S +C C to act on my behalf, in all matters relative to work authorized by this building permit application. Signatur Owner Date " o 5 , as Owner /Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. G n fl - Print Name - do) Signature of Owner /Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size ©' 49 ct(.n) I ' 3y' I I' Frontage _ — ) 0 + Setbacks Front I et)' f ,duo`+ /- Side L: R: L: R: 4 Rear Building Height j cP t Bldg. Square Footage % Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: ( I� (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO '►® DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO C. IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or fining) over i acre or is it part of a common pian that will disturb over 1 acre? YES NO to YES, then a Northampton Storm ate Managemen - ermit from the DPW is required. '�' Department use only :� 6 0� City of Northampton Status of Permit: , 3 uilding Department Curb Cut/Driveway Permit No , 2 12 Main Street Sewer/Septic Availability , F . W , Room 100 Weer/Wen Avallability of -a?‘ .c Northampton, MA 01060 Two Sets of Sctura Rims phone 413- 587 -1240 Fax 413- 587 -1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office 8 / e n gc( Map Lot Unit Flo 2 e n L e 1 O✓i 1 6 1°64 Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: r 11.114 Name (Print) Current Mailing Addfess: O i o to ) e t , e� ` /1444-24.—_-- Telephone Signatur 2.2 Authorized Anent: Name (Print) Current Mailing Address: Pi A O 10 ,,, +1 413 - 71'71 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building La, oo (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) f s f S 5 L 5 76, — 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) ) 10, 00 0 Check Number It 34 : ;, This Section For Official Use Only Date Building Permit Number: Issued: Signature: -� -- / I C "....-...- g1 f Building Commissioner /Inspector of Buildings Date '° (-1‘) 6 r,_ ---- pR OK — 0 r... ris,,,,K, 881 RYAN RD BP- 2013 -0248 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35 - 067 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: shed BUILDING PERMIT Permit # BP- 2013 -0248 Project # JS- 2013 - 000318 Est. Cost: $16000.00 Fee: $70.40 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOMETOWN STRUCTURES 98186 Lot Size(sq. ft.): 12806.64 Owner: ADAMS JANE Zoning: Applicant: HOMETOWN STRUCTURES AT: 881 RYAN RD Applicant Address: Phone: Insurance: 627 SOUTHAMPTON RD (413) 562 -7171 WC WESTFIELDMA01085 ISSUED ON :9/6/2012 0 :00 :00 TO PERFORM THE FOLLOWING WORK: REPLACE 11 X 15 SHED W/16 X22 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 9/6/2012 0:00:00 $70.40 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner