42-125 (6) BP-2023-0802
142 GLENDALE RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
42-125-001 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-2023-0802 PERMISSION IS HEREBY GRANTED TO:
Project# GAZEBO 2023 Contractor: License:
Est. Cost: HOMETOWN STRUCTURES 98186
Const.Class: Exp.Date: 08/03/2023
Use Group: Owner: COMMUNITY CARE RESOURCES INC
Lot Size (sq.ft.)
Zoning: WSP Applicant: HOMETOWN STRUCTURES
Applicant Address Phone: Insurance:
627 SOUTHAMPTON RD 4135627171 WCC-500-5026065
WESTFIELD, MA 01085
ISSUED ON: 06/23/2023
TO PERFORM THE FOLLOWING WORK:
12 FOOT GAZEBO
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 NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
V ; % ;
Fees Paid: $30.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
2--ok
File #BP-2023-0802
APPLICANT/CONTACT PERSON:HOMETOWN STRUCTURES
627 SOUTHAMPTON RD WESTFIELD, MA 01085 4135627171
PROPERTY LOCATION 142 GLENDALE RD
MAP:LOT 42-125-001 ZONE
THIS SECTION FOR OFFI IAL USE Y:
PERMIT APPLICATION CHECKLI T
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Building Permit Filled out
Fee Paid $30.00
Type of Construction: 12 FOOT GAZEBO
New Construction
Non Structural Renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans/Plot Plan
Driveway Grade%
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 Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Varance*
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
Ir
, (/3,3
Signal re 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 standards of MGL 40A.Contact Office of
Planning&Development for more information.
City of Northampton
►` l�r-,.› S,,y sj.
b 1 Massachus- ,4? �-
l'tr
_,\ ' {�i. \ ,••k DEPARTMENT OF BUILD NG -��M ' - I V E -J
. 212 Main Street • Mu icip:1 Building
Northampton, . 0 060 iy l,,, "
JUN 2 0 2023
D .NORTH OL DING I
A ,ON.MA 07060ONS
ACCESSORY STRUCTURE PERMIT APP • ON
(For freestanding structures 200 sq. ft. or less, at least 10 feet from any other structure)
Application fee Is$30
'10" 33 7 0 2.
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: Hom e-1-d w, S•t rti c I ei r e p , i.L C
Address: 6Z7 S^Ouftigk,f/bh Rdrkiedir..ee/d,Mirelephone: T/3 —.5-62-7/7/
2. Owner of Property: (40 AA n+ “h, 7(1/ l_q ce A e c B(t r c e 1 H C
Address: 3 36 B rrr rl Ise A/C, S�r s(30 t I Mil OTelephone: ! 1 3 - 4-C9- ( 2 0 2-
3. Status of Applicant: Owner Contractor
4. Structure Location: /7 ? G-/e v1 DI Gi /e Ai
Parcel ID:Zoning Map# Y' 2- Parcel # 12 C District(s) A 5 P
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5. Use of Property: Single or Two Family: t/ Multifamily: Commercial:
6. Description of Proposed Structure:
One Story Shed under 200 sq.ft.: Freestanding Deck under 200 sq.ft.,less than 30"above grade:
SIZE OF STRUCTURE:
Other(describe): 12. / Oc f a ja r, &-a Z e .l-o Fie SA A d,�,
/ 9
7. Attached Plans: Sketch Plan V Site Plan Plot Plan /
8. Does the site contain a brook, body of water or wetlands? NO ✓ DON'T KNOW YES
IF YES: Has a permit been, or need to be, obtained from the Conservation Commission?
Needs to be obtained Obtained , Date issued
CONTINUED ON NEXT PAGE
9. ALL INFORMATION MUST BE COMPLETED; PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION.
This column to be filled in by
the Building Department
Existing Proposed Required by Zoning
Lot size g 6 S` acre s
Frontage N/A N/A N/A
Front: I0U -I *
Setbacks: Side: L•' S2 4f /r ' co.F{.
Rear: 11 7 f f
Height 6 z l v1
Open space:
(Lot area minus bldg and
paved parking)
10.Certification: I hereby certify that the information contained herein is true and accurate to
the best of my knowledge.
DATE: -' /b ?Oa3 APPLICANT'S SIGNATURE 0
NOTE: Issuance of a permit does not relieve an applicant's burden to comply with all zoning requirements
and obtain all required permits from the Conservation Commission, Department of Public Works and other
applicable permit granting authorities
41-001401
124
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DI 42-125-001
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-T . 42-124-001
OW
150
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csa
12' Octagon Wood Gazeboes due to
requirements on
each protect T1U pion le Mended d to relied only tie @trudvd
dodo d Ns bid The cornread old redo el.poked.toed (A
t General �
state and Wend bui3np aocode,odor to toalert d aorsrruo6on toA&metro!wood members end casidai dot be d added etas
ooze!drip!dripooriclrr,euca Tuber Tech 6,�ierlrlg,heheY not or cepedty to carry el deign bads smut exasec ing to eboeble
raspas�ls for Itorm.tlon paneling to tie prgsd I not shown an deign velum spaded h lbs NdaW Design spedoafbn tor
dodge er faded belowbelowRedstoneRedstoneto the low sill be approved
by aWood __on'SOB).2005.ddon,and b'94pletnwd'by to
d record ... ten_F_arad end Paper Aeeoddan F-+PA).
IMIKINBISAMIEHIS Et Wood members used for bed appora,p popped Vial hays tie grade
t Oow►ri10 Cods met of a lumber Red-agency carded by he America,Unbar
hdudhg not hied to'BC 2006 Mender*Camilla
2 Deed Loads 2 DMndan Curter
A.Rod 5 pot A.Al lunar species.graded Andy or rriddicry,del comply sal to PCS
The drawing Is the property d Country Lane Woodworkhg,LLC, a.Mar nn/a pad DDeperti by o t a C end omore*.
ore*.�Softwood LibberStandard�B 20 ao by Iseus
provided by Timber Tech Engheerhp,Inc.and reproduction, a Live Loads a Tt,e dirun grade end.pasbs for pods,biutni header.,end o der prtnary
A Root(Sn goo note 04) 403 lot ehietrel members slid b.Dense Stied Stiotiri 8ou11nern Pie,idea spaded other des.
alteration or use of this drawing without the written consent d a Floor 40 pot C.Unrber used for ueccodry terring del be Ill 8a warn raw line CM)or better.
Cou*y Lane Woodwort(hp, LLC is prohbled Drawings shell not cooevar nia p D.Sttsa.d deed writ d arbor del conam with he'Amarke,Mull ale derd
be scaled to obtain drnefldofla. The Contractors end binders 4 A land aww o'b1 CO pi E se Snow Lode Specdadon er w acorn shot e A 1 AABAE Okted Untitled Timber EP�
Involved on this project shell verify el einenslons and oondians a Flat Rod Snow CPO 403 pet a Presor.Preeerv.t a Treatment OPT)
before starting work end any discrepancy shut be reC aloe elms"
Factor(C.) 10 A.Presume
oPresee Vestment the to be performed acocrd b Anneloan Wood Protectionn
f0 the D.arise load Important),Factor(0 0B Aeeodefan(AWPA)d.nd.rde for tea category 38(.hose ground.'pmeca
engineer In twithg before shorting work. E Widened Snow a Preside treated mentors did have M bipedal mirk d en agency aztedied by he
L Whdwrd Rod 0 pot Mmerben Limber 8hende►ds Camitss.
I Leeward Rod 20 pot to 50 pot C.Presevdrs Armonk Copper Ouslerrory armnaie(ACO)or Capper Boron Asps(CBA)
5t Whd Load D.Tree!bloated More end M blade
A Bede Wind Speed M 146 mph WO t Wood minters expand to seder or Insect treddlon.
a Wind Load Unbalance Factor 0) 77 2.Wood murders h dad canal din sorb or oa svate.
C.Wind ewers embody C a Wood members exposed to lash moitre content Old for dhwwtan tuber,)16X for glued
D.Endo.i.Category Cps± Misted utter).
E Carparent,end Clad&np -40 pot/-40 pot 4 Wood mentors lees Mn 12 bees above grads
2 Eir/hgtet.Dedgn Dale E Rod treat net/exposed wood where suing.drill;or nodding prsutr.treated Leber.
(And el.bawd on a .vale t Meryl force pocadr.) F.Al bob used In double rafters did be abbess steel or hod dpp•d warded as per ABTLI
A. Spedtal Rsaporrs Acoelendon A156.O1a AI other meld fasteners tad In reseed wood del be shelled red hoNds
at 1 sec 8 025 minded es per AM A159-O s,or other posing approved by fastener muds krer for
II festal Response Moderation d short we In raved wood
parade,8 040 4 Casictaw old be deeaid and coroln tsd aocardg b M M8 by AF-WA all steal
Drawing Index aCp us 1Use Grab conform a Factor tp *4mem b the blowing
did be two 12 penny rids,or es deleted an M dmshpa
E Ell.Cole D a Other comedians s per Mended caurudlon prado .
Page 1 - Elevation, Post Layout Plan F.
30,E noted diodes.
;""""°b'"M"'"�6d'"" ""
Carilu•r.d Cohn Thrber liens
Page 2 - Roof Framing, Cross Section L D. action F.(d) 15
Page 3 - Details
Page 4 - Details Design Reaction Chart
Max uplift at column base 250 lbs
Page 5 - Details
Max downward force at t1o0 lbs•
ALTERNATIVE ROOFNG: column base
Page 6 - Details The bfe T and a 41 srP dsdlhp and asphalt shingles Max.shear at column base 70 Ibs
may be replaced by bx4 pultti•8'o/c and 24'long
ceder dikes it areas d Lai to 45 pe grand snow load •Reactions from floor loading not Included. Floor framing
and 120 mph rand NM speed eukiect to local members are assumed to be continuously supported by a
l„le:9A „approval). concrete or gravel pad or other support structure.
, TIE MAIMS PLUM @1e11
JOB NUMBER:E219-11 PROJECT:STANDARD PLANS FOR 12' This drawing is the property of Country l one Woodworking,[LC.provided by Timber Tech Engineering,Inc.and reproduction.alteration or use of this drawing without the
written consent of Country Lane Woodworking,LLC is prohibited. Drawings shal not be scaled to obtain dimensions. (he contractors and builders involved on this project
PAGE:1 OF 6
OCTAGON WOOD GAZEBO
shall verify all dimensions and cons bons before starting work and any discrepancy shall be reported to the engineer in writing before starting work
7m
,....r____...______......2...._r___...._————___._ _..-.. ......._...--. ._...-•—'"- -- •-•--- —.....„: ,.§ /
,ate
I.
a
III
iu
//iii. III
11.
9i� oil
`1 s:
Framing Elevation NTS Elevation
NTS
_ V-9v4 _
tt.________.14'.-5Y2. .
ti
4
4x4 poet 4x4 post
IA
----------(2)2x8 floor joist
IA \-2x6ekPtboard
• * r ` I
* ® e- 2x61loor Joist
1F-49/E•
Post Layout Plan Floor Framing PlanNTS
y NTS Fully Assembled Unit
JOB NUMBER E219-11 PROJECT: STANDARD PLANS FOR 12' This drawing is the property of Country Lane Woodworking,I IC.provided by Timber Tech Engineering,Inc.and reproduction,alteration or use of this drawing without the
written consent of Country Lane Woodworking,LLC is prohibited. Drawings shall not be scaled to obtain dimensions. the contractors and builders involved on this project
PAGE:2 OF 6 OCTAGON WOOD GAZEBO shall verity all dimensions and conditions before starting work and any discrepancy shall be reported to the engineer in writing before starting work
1T-1o%
2x6 wedge block,to support
i"' roof decking,fasten to top
4A1
plate w/(2)120'x3'nail
from underside
1;211
-4x42x6poet comprseeion ring/—
\ /� 2x8 top plate
�•I\ --(2)2x4 hip rafter
;I
` —2x4 fascia
44\4\k"i\i, MINIIIIId
Roof Framing Plan NM
17%
Pre—fabricated cupola
2x6 compression ring
Asphalt shhglee
(2)2x4 hip rafter
Q76 ' 1x6 T+Ci 81 SNP decking
2x8 top plate
Detal E-S/3
1T -' -Detail A—A/3
•
T 2x4 fascia
g T ,._.-4x4 post
b '------2x4 top rail
2x6 Ong Detail C—C/4 2x4 bottom rail
II
2x6 skirt board
11
-----.....,:............„.........._
(2)2x6 floor joist
Cross Section A/2NTS
JOB NUMBER:E219-11 PROJECT:STANDARD PLANS FOR 12' This drawing is the property of Country lane Woodworking,LLC,provided by Timber Tech Engineering.Inc.arid reproduction,alteration or use of this drawing without the
OCTAGON WOOD D GAZEBO written consent of Country Lane Woodworking,LLC is prohibited. Drawings shall not be scaled to obtain dimensions. the contractors and builders involved on this project
PAGE:3 OF 6 shall verify all dimensions and conditions before starting work and any discrepancy shall be reported to the engineer in writing before starting work.
1x6 T+Ci 01 SYP decking,fasten to ratters
w/(2)2'galvanized staples w/t crown
Asphalt shingles 3 tx5 txk cap plate of T-\
assembly on top of poet
Fasten rafter plies together I
Mote
w/(3)II bolts for kit unite OR ,
..:. v O„""�CLAFITY --
8d nale 12' o/c staggered - ik` -., 0
for My assembled unite, \_2x,
(x-nal from other side, 1x4 trim,fasten to fascia w/2'
o-nail from near side) paw_.; galvanized staples w/ 'crown 6'o/c —_
i:G�`
(2)2x4 hip rafter,fasten .. `I' 2x4 faada,fasten w/
to top plate w/(2)Angle'Az eiox2 i'wood ac rews,18'o/c
I'+bolt Trim assembly w/2x4 top and
bottom rails,and 1x4 vertical plate- 4x4 P�
2x8 top plate ix4 fastened to post wl(6)f'IOx2_ '
x. s 1 - 2 k x2'xe'x3 a ample of'T' wood screws,staggered -2x6 brace fasten
3 e e xe cap plate of T assembly,fasten to post at top w/(3)t110x3 '
tassembly faateno post wtop of%(4 and top plate w/(4) wood screws and at
010x2 'wood screws �'wood screws,each bottom screws i •gx2
4x4 p
Detail A-A/3 NTS View 1 Detail A-A/3 NTS
2x6 compression ring
,--- 'x6(2)2 'xe'x3;,steel angle
'A2',fastened to 2x8 top plate 1x6 T+G II SYP decking,.
'w/(10)010x1 wood screws,each fasten to rafters w/(2)2
' galvanized staples w/r crown
* '', Fasten rafter plea together : alt
shimies
• w/(3) i+bolts for kit units OR
8d nails 12'o/c staggered r�
for fully assembled units, ,
Angle.�• (x-nail from other side,
iii
(1)tf bolt,through double o-nail from near side)
rafter on both kit and
My assented (2)2x4 hip rafter,fasten t•
compression ring w/(2)
I10x3 t wood screws each ply
View 2 Detail A-A/3 NTS Detail B-B/3 NTS
JOB NUMBER:E219-11 PROJECT: STANDARD PLANS FOR 12' This drawing is the property of Country Lane Woodworking.LC.provided by Timber Tech Engineering,Inc.and reproduction.alteration or use of this drawing without the
OCTAGON WOOD GAZEBO written consent of Country Lane Woodworking.LLC is prohibited. Drawings shall not be scaled to obtain dimensions. The contractors and builders involved on this project
PAGE:4 OF 6 shall verify all dimensions and conditions before starting work and any discrepancy shall be reported to the engineer in writing before starting work.
4x4 poet
i 4x4 post (2)2x6 floor joist 2x6 skit board,fasten each end
to joist w/(2)0.12rx325'nails OR
2x4 bottom rat (2)410x3 j'wood screws except
Poet strap 1 on two aides of post,fasten �.ASt
, when alternative angle location is
2x6 dec ng to poet w/(4)NA 'wood screws 2x6 blocking then fasten each end to
►Z�
•
2x6 skirt board ,� 1 w/(5)0.12rx325' Hale OR
ikw
(3)410x3 t wood screws
ram, Post base 1 •
Alternative angle location .11 M i i 0►
2x6 floor joist r mg s,
--Angle•Ar fasten s i bolt at post bass
to joist w/(5)410x21/2'wood Angie'Al'fasten
Concrete foundation-- _� ,, screws and fasten to concrete to joist w/(5)410x21/2'wood
by others ,Mo— foundation(fc-3000 psi min.) screws and fasten to concrete Alternative angle location
(3000 psi may) w/1'%x4' Powers Wedge-Bolt foundation(fc-3000 psi min)
screw anch or equ�a- - w/ '4x4' Powers Wedge-Bolt a
Detail C-C/4 NTS mew any,or
equal
Kit Unit
View 1 Detail C-C/4 NTS
Kit Unit
2x6 skirt board,fasten each end
4x4 post to poet w/(2)0.12rx325'nails OR
<p
(2)2x6 floor joist fasten to 2x6 (2)*IOx3 'wood screws except
blodcig w/(4)0.12rx3�' nails,each ply when alternative angle location Is
chosen,then fasten each end to
4x4 post post w/(5)0.121x325'nab OR
2x6 deckhg ► - 2x4 bottom rail (3)#10x3 'wood screws
. 2x6 skirt board 11
Angle'Al'fasten 0
j
�''r to joist w/(5)410x21/2'wood /
screws and fasten to concrete Angle'Al'fasten ,
2x6 floor joist �. foundation(fc-3000 pet min) to joist w/(5)410x21/2'wood
w/ 'tx4'Powers Wedge-Bolt screws
and fasten to concrete \—Altemative
e
location
screw anchor,or equal
(fc-3000 psi Min.)
Concrete foundation - Alternative ante location w/ilx4'Powers Wedge-Bolt
�,others�� 2 screw anchor,or equal
(3000 psi mh) 2x6 blockng,fasten t•
Detail C-C/4 Nis Poet w/(6)0.12rx325'Hale
Fully Assembled Unit View 1 Detail C-C/4 WTS
Fully Assembled Unit
JOB NUMBER:E219-11 PROJECT:STANDARD PLANS FOR 12' This drawing is the property of Country lane Woodworking,LTC,provided by Timber Tech Engineering,Inc.and reproduction.alteration or use of this drawing without the
OCTAGON WOOD GAZEBO written consent of Country Lane Woodworking,LLC is prohibited. Drawings shall not he scaled to obtain dimensions.The contractors and builders involved on this project
PAGE:5 OF 6 shall verify all dimensions and conditions before starting work and any discrepancy shall be reported to the engineer in writing before starting work.
V
2x4 top rail,fiat --NI\-- wood post, beyond
8-9V rr a an rail sese rttly length
{r S-e'rnaxtnun top rill length
I4' 4' �_'t:? t-r,edge '1.12x4 top rail,flat
r
J 4
Mit
1x3,on edge
14.square epinde OR decorative lathe,4'o/c
t ' - .ei l ,—1x4x37 i'vertical end plate -
htop rail w/(3)#8x2 l' wood screws,fastened
to to
to 1x3 w/ (2) 2'galvanized staples w/k crown,
and fastened to 2x4 bottom rail w/(2)#8x2 k
wood screws Fasten 1x4 vertical to poet
near top plate w/ (3)118x2 Z'wood screws
, I and near bottom plate wl(2)48x2 l'wood screws
i 1x3, on edge
A_ --2x4 bottom rail,flat \ 1x3, on edge 2x4 bottom rail, flat
1 4' square apinde OR decorative lathe,4' o/c
1x4x37 2'vertical end plate fastened to 2x4
top rail w/(3)#8x2 k wood screws,fastened
to tx3 w/(2)2'galvanized staples w/ k crown, View 1 Hand Rail Elevation NTS
and fastened to 2x4 bottom rail w/ (2)#8x2 l'
wood screws. Fasten 1x4 vertical to poet
near top plate w/(3)#8x2 r wood screws
and near bottom plate w/(2)$8x2 k wood screws
Hand Rail Elevation NTs
JOB NUMBER:E219-11 PROJECT:STANDARD PLANS FOR 12' This drawing is the property of Country Lane Woodworking,LLC,provided by Timber Tech Engineering.Inc.and reproduction.alteration or use of this drawing without the
OCTAGON WOOD D GAZEBO written consent of Country Lane Woodworking,LLC is prohibited. Drawings shall not he scaled to obtain dimensions. the contractors and builders involved on this project
PAGE:6 OF 6 shall verity all dimensions and conditions before starting work and any discrepancy shall be reported to the engineer in writing before starting work.
s• 12 QA.galvanized steel �•+hole for 48x1 .
T •_ wood screws
3•x3'x3',10 go. _ -
steel angle II1 - 44. ,
r ° ° 'vk MEM 11,
,
w2..L 4
I.
I•+hole for wood
didscrews(1 Cl 5) r
e+hob ,,'
t+hole for t bo4
Angle "Al Nrs Post Strap 1 NM
Al hole far •+bolt Kit Unit
i'+holes for steel screws
00/
2 •x6•x;•x3;steel angle•A2•
e,steel ' • t+hole for wood
screw(1 of 10)
r 4
34• 6. • •• T T t+hole for wood
�° / • Hall l r screws(1 a 8)
ira.,o
I•:
° 0
® P.
''pji,,,o._ ,,
Angle "A2* NTS 403
+hole for +bolt 8
v�m3t r
'gymniiii74111.=,
---
....____T____,:.1 i----8—h7Sg(-1 .-10.1
Post Base 1 NTS —'ll-r3— e1.--1-
Kit Unit "T' Assembly NTS
Commonwealth of Massachusetts
11 Division of Professional Licensure
Board of Building Regulations and Standards
,>nstrttCtiOhl4 pervisor
CS-098186 Expires 08'03 2023
ANDREW D KURTZ
118 PLEASANT STREET
GRANBY MA 01033 toy
, 4*
00
Commissioner ,jailfi. b1C4flL tv
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
f1-1
z4
Type: LLC
Registration: 159772
HOMETOWN STRUCTURES, LLC 17;! '" Expiration: 05/26/2024
627 SOUTHAMPTON RD awe
4
WESTFIELD, MA 01085
Ti
r. ;
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
ANDREW KURTZ
627 SOUTHAMPTON RD fx,�' r -zi�•
WESTFIELD,MA 01085
Undersecretary Not valid with signature
The Commonwealth of Massachusetts
Department of Industrial Accidents
f,_ Office of Investigations
1 ,--;; , Lafayette City Center
2 Avenue de Lafayette, Boston, MA 02111-1750
www.mass.govldiaI
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/organization/individual): Yd pv, e 'oijyt 5/% Uc -ie(r Cy L.I. C
Address: a. 2? ..,), cr
City/State/Zip: l,tI<.,( / 1/ I, 4 I I)/0 . Phone It: /3 7_ -- 7/7
Are you an employer?Check the appropriate box: Type of project(required):
1.Q I am a employer with 2.S' 4. ❑ 1 am a general contractor and 1
employees (full and/or part-time).* have hired the sub-contrtctors b• ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have $. ❑ Demolition
working for me in any capacity. employees and have workers' 9. Q Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. [] We are a corporation and its 10.0 Electrical repairs or additions
3.Q 1 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
employees. [No workers' 13.pi Other qCe-p__.(Su7x'f'. 11+ t//(
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.
tContractors 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: Th r 90/t4 / e h c, s- f I C.
Policy#or Self-ins. Lie. #: W C(- SO o- c.0 a.gO,c 5--2 o2 2, Expiration Date: 1/-2 7" 2 02 J
Job Site Address: I if ?c C.,.I p.J,/ , o q d City/State/Zip:/go 'ht m f icoikA 0l 0 W.-
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 infrurmation provided above is true and correct.
Signature: (141%-4,,, ! _....... Date: L, - / t,, - 0 2o a 3
Phone#: 0. - 5 (' )- -71-7 l
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 one):
10Board of Health 20Building Department 3fCity/Town Clerk 4.QElectrical Inspector 5P'lumbing
Inspector 6.QOther
Contact Person: Phone#: