46-050 (6) BP- 022-0937
99 ISLAND RD COMMONWEALTH OF MASSACHUSETTS
Map:Block;Lot:
46-050-001 CITY OF NORTHAMPTON
Permit: Acc Structure
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2022-0937 PERMISSION'S HEREBY GRANTEI TO:
Project# SHED Contractor: License:
Est. Cost: 21935 HOMETOWN STRUCTURES 98186
Const.Class: Exp.Date:08/03/2023
Use Group: Owner: ADAM BASS, KATHRYN &
Lot Size (sq.ft.)
Zoning: SC Applicant: HOMETOWN STRUCTURES
Applicant Address Phone: Insurance:
627 SOUTHAMPTON RD 4135627171 WCC-500-5026065
WESTFIELD, MA 01085
ISSUED ON:08/12/2022
TO PERFORM THE FOLLOWING WORK:
DEMO GARAGE -BUILD NEW 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:
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 NOI2THAMPTON UPON VIOLA ION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
I !Ay .>2 .
• .Fees Paid: $82.80
212 Main Street,Phone(413) 587-1240.Fa x:(413)587-1272
Office of the Building Commissioner
File #BP-2022-0937
APPLICANT/CONTACT PERSON:HOMETOWN STRUCTURES
627 SOUTHAMPTON RD WESTFIELD, MA 01085 4135627171
PROPERTY LOCATION 99 ISLAND RD
MAP:LOT 46-050-001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Building Permit Filled out
Fee Paid $82.80
Type of Construction: DEMO GARAGE BUILD NEW SHED
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:
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Perm it With Site Plan
Major Project: Site Plan AND/OR SpecialPennit 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 Wa ter Availability Sewer Availability
Septic Approval Board of Health Well Wate Potability Board of Health
Permit from Conservation Commission Permit f om CB Architecture Committee
Permit from Elm Street Commission Permit PW Storm Water Management
Demolition Delay
Ig71//2')
s2 qe.A
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 sta ndards of MGL 40A.Contact Office of
Planning&Development for more information.
R EIV-7-
The Commonwealth of Massachuse
W
Board of Building Regulations and Stan ards A UG - g 2C FO
Massachusetts State Building Code, 780 CM 2[vIU ICIP LITY
US
Building Permit Application To Construct,Repair,Re ovaifgrEki ed ar 2011
One-or Two-Family Dwelling RTI�AMF�TON•'MA Oe060 NS
This Section For Official Use Only
Building Permit Number: M-447. %/�7 Date Applied:
ii : Ili �?
Building Official(Print Name) Signature Dat
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Asse spprs Map&Parcel Numbers
(pi 7-c 1 o d (load, Nor-f ham?ton,MA d1cX60 SO -DO
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
SC
101
so '
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 T
So ' yl iy/R3y` y" V'
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Dill Private❑ Zone: _ Outside Flood Zone? Municipal ri On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: /f
2a'owski �Ca+kryn /Var--a .-on, MA O1 o(ol
NamerPrint) City,State,ZIP
99 )a J Road 4-(ol7--y96$ I @QQrna;I.coin
No.and Street Telephone Ema'l'Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) ❑ Addition 0
Demolition W Accessory Bldg. ' Number of Units Other 0 Specify:
Brief Description of Proposed W� ork': DvoI; -!'an, o4 exLs4-4.1 1raye
coAs�oWo,, 0./ ateActriv o rces-ory c+r,,(4 C) d,. .Si ZK_ I2 'x '22
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 21 R3S.00 1. Building Permit Fee: $ Indicate how fee is determined:
I ❑ Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costa (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List: —
5.Mechanical (Fire $
—
ir)
Suppression) Total All F�s��o a
_ Check No. heck Amount: DOS Cash Amount:
6.Total Project Cost: $ 21 cI.3,•00 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
((�� 1 CS -0 9 8-1 Y6 o8103�20 23
Andrew J kvrh License Number Expiration ate
Name of CSL Holder
List CSL Type(see below) U
118 Pies aA4 Sues.}
No.and Street Type Description
Graitb y MA ,t� lo� 2 U Unrestricted(Buildings up to 35,000 cu.ft)City/Town,State,ZIP V R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
413- 2-7171 pnarC w @home4o4vAS+rt,dtir f s.Cam I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /59?7 Z S (a 2o2Y
HIC
4 wit S�rvckre t L L6 HIC Registration Number Eftppirati5n Date
HIC Company Name or HIC Re trant Name
(027 S«,+I,an 4o goad are4v@konnt-EawaS4Fr0c�vres,CoM
No.and Street Email address
W.-.+a'9 Ii, /WI 0►085 4i3-,%2-71 i►
City/Town,State,ZIP 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 provid
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes nif No 0
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 H o/►ne_Aji,t,ri S+fc/Ch.,res L LC. _
to act on my behalf,in all matters relative to work authorized by this building permit application.
X /�� 5�aa- X 5 August 2022
Print Owner's Nan (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.
anAotuft, g- s - ?o?i
Print Owner's or Authorized ' 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.) 2 / *Id- (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" 1
Commonwealth of Massachusetts
(110 Division of Professional Licensure
Board of Building Regulations and Standards
Construction Supervisor
C S-098186 Expires: 08/03/2023
ANDREW D KURTZ ;
118 PLEASANT STREET
GRANBY MA 01033
Commissioner a fi. 14-nc,ia.,
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
^' .. Type: LLC
WIMP ._.. Registration: 159772
HOMETOWN STRUCTURES, LLCExpiration: 05/26/2024
627 SOUTHAMPTON RD ' •
_
WESTFIELD, MA 01085 _
rfj . Aru
i ti ___,
��1
Update Address and Return Card.
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the
HOME IMPROVEMENT CONTRACTOR expiration date. If found return to:
TYPE:LLC Office of Consumer Affairs and Business Regulation
Registration Expiration 1000 Washington Street -Suite 710
159772 05/26/2024 Boston,MA 02118
HOMETOWN STRUCTURES, LLC
KURTZ
627 SOUTHAMPTON SOUTHAAMPTON RD id.�„kof, ,/Q��t" 1
WESTFIELD.MA 01085
Undersecretary Not valid withou gnature
The Commonwealth of Massachusetts
= /, Department of Industrial Accidents
, 1_ 1 Congress Street,Suite 100
C__ ��_ " Boston,MA 02114-2017
, _ - www mass.gov/dia
Yorkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Lettibh
Name(Business/Organization/Individual):Hometown Structures
Address:627 Southampton Road
City/State/Zip:Westfield, MA 01085 Phone #:413-562-7171
Are you an employer?Check the appropriate box: Type of project(required):
1.Q I am a employer with 22 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.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
14.❑✓ Other accessory building
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.]
*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:The Dowd Agencies, LLC
Policy#or Self-ins.Lic.#:WCC-500-5026065-2021 A Expiration Date: 11/27/2022
Job Site Address:99 Island Road City/State/Zip:NorthamptonMA 01060
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: CQ..J_.µ. XL-•.... Date: g—S— 22
Phone#:413-562-7171
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
Contact Person: Phone#:
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800) 876-2765 NCCI NO 40959
POLICY NO. WCC-500-5026065-2021A
PRIOR NO. NEW
ITEM
1. The Insured: Hometown Structures Inc
DBA:
Mailing address: 627 Southampton Road FEIN:"-"'6332
Westfield, MA 01085
Legal Entity Type: Corporation
Other workplaces not shown above:
2. The policy period is from 11/27/2021 to 11/27/2022 12:01 a.m.standard time at the insured's mailing address.
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 work in each state listed in item 3.A.
The limits of liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 100,000 each employee
C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE
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.
Classifications Premium Basis Rates
Code Estimated Per$100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
INTRA
INTER SEE CLASS CODE SCHEDULE
Minimum Premium $500 Total Estimated Annual Premium $16,249
GOV GOV Deposit Premium $4,230
STATE CLASS
MA 2802 State Assessments/Surcharges
$16,044.00 x 4.1800% $671
This policy,including all endorsements,is hereby countersigned by ' 11/11/2021
Authorized Signature Date
Service Office: The Dowd Agencies LLC
54 Third Avenue 14 Bobala Road
Burlington MA 01803 Holyoke, MA 01040
WC 00 00 01 A(7-11)
Includes copyrighted material of the National Council on Compensation Insurance,
used with its permission.
Owner:
Address: 'Zajo
Wski at
Parcel ID 99 Island RoadUse Code: Northampton,MA 60
0/0
Acres: 7127/238
Zoning: 0.08
Water/Se SC
wer:
Municipal
soft
T 34= co
4'
O
SO'
48 t
oad
istand Ft -
City of Northampton
MassachusettsDEPARTMENT OF BUILDING INSPECTIONS•
i` —s 212 Main Street • Municipal Building ,
--� Northampton, MA 01060
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In 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: �� I 'Iv�l en �QQ�, E 41),'cl) C -r Dg2
The debris will be transported by:
Name of Hauler: USA JUS4e and R >1i;j
Signature of Applicant: 0 Date: F-S- 22
30-year architectural 2 x 6 rafters 16" on
shingles over 1/2" CDX ,. center with collar
plywood roof sheeting ...„,„- . . _
ties 4' on center
, ., ,
ridge vent
ef "'att._
s": �, s's. - '' , : ' -/ -40,1' ' .1:10
exclusive detailing, % ,• .,
with large roof overhang - . • 101- ,,
0* ...-- .- i
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j.. ,, ,,.:„ , f_.�
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# ' ,A\,. , 1 P10, -__ 41'4°':,,,
/`
double 2 x 6 header k_
over windows and doors pressure treated floor
1\4\4'4%
system, 4 x 4 rails, joists 12"
on center, 5/8" plywood
vinyl over 1/2 CDX plywood
Hometown Structures Sales Order
627 Southampton Road
Westfield, MA 01085 Order: 0-12257
(413) 562 7171 Date: 7/28/2022
www.hometownstructures.com Lead Time: 8-10 weeks
Structure Layout (not to scale) Deliver To:
Custom Built Assembled 'OW Wall I� Addi Bass & Kathryn Zaj9wski
99 Island RoadI
Vinyl Shed II Northampton, MA 0106b
New England
Studio Phone: (860) 617-4968
Email: alizerin@gmail.com
High Wall
12 x 22 _ — = =
Colors Types Description Qty Rate Amount Tax
Drip edge White Floors,Walls, Roof 12,955.00
Siding Light Gray Base New England Studio 12 x 22 (included)
Roof Dual Black Wood Floor 2x4 Joists,spaced every 12" (included) W
Trim White Siding Vinyl Siding (included) W
Corners White Roof Architectural Shingles (included) ❑�
Doors White Insulated Floor Insulated Floor($1,055) (included) W
Windows White Doors&Windows 5,750.00
Doors Prehung 36x72 Single Door F-C 1 450.00 450.00 0
Doors Prehung 61x72 Double Door F-C 2 1,000.00 2,000.00 0
Notes: Windows Transom Window 10 x 35, Insulat 1 150.00 150.00 0
No grills in the doors or Windows Transom Window 10 x 29, Insulat 10 150.00 1,500.00 W
windows Windows Standard Window 30 x 36, Insulat 4 300.00 1,200.00 El
Windows Standard Window 24 x 36, Insulat 2 225.00 450.00 W
Accessories 240.00
Tyvek House wrap 1 240.00 240.00 0
Services 3,072.80
Site Prep Stone pad for 12 x 22 structure 1 1,150.00 1,150.00 ❑
Site Prep Demolition of existing 12x22 struc 1 1,800.00 1,800.00 ❑
Delivery Overwidth Permit 1 40.00 40.00 °
Permit Building Permit 1 82.80 82.80 ❑
Subtotal $22,017.80
MA Tax 6.25% $1,184.06
Total $23,201.86
Customer Signature
Receipts $5,000.00
fly„;. Balance $18,201.86
Sales Person:Darvin Martin
Additional Images for 0-12257
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