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30 -year architectural 2 x 6 rafters 16" on
shingles over 1/2" CDX center with collar
plywood roof sheeting ties 4' center
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•
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•
HOMETOWN INVOICE
S TRUCTURE S - •
„..40k‘...,, 627 Southampton Road Order Date 9 - .97- dal
- _ -- __ ' Westfield, MA 01085 1329 Estimated Completion Date �"
_ = (413) 562 -7171 •
Bill To ,j (3 K.. Db Notes
Address 1 19 /Ue-'F /ncrie Sf .
f t o rcn cf,.., /'1 /4 () /0. (6 ,
Phone # S 0 A/ `/3 Cell Phone # _
E -mail Address ,
U In - stock Display Shed U DuraTemp T1 -11 U X Vinyl
4 To Be Custom Built Body Color Body Color C mc—.r.
. !' Delivered Fully Assembled Trim Color Corner Color L.. FZ
CI Modular Door Color Door Color 1 ---%ti i'I-e-
U Built On site SOFFIT CHOICE (For New England Style Only) SOFFIT CHOICE (For New England Style Only)
+ Solid T1 -11 U Body Color Perforated Vinyl Li White U Brown
Size / x Exposed Rafter Tails U Body Color Beaded Vinyl )(White Only
4 New England Series Aluminum Strip Vent U White U Brown
U Keystone Series Base Price $ t, 2 ( f' }
St BU rz..w F.- J R pair k pit ,-ri 0 -- 3 . \I
Code Q3' : S Door Adjustment $ `79
Shingles Windows Window Adjustment $
• U Dual Black U 18" x 36" Ramp ❑ 6' x 4' ❑ 5' x 4' ❑ 54" x 4' ❑ 2� $
U Earthtone Cedar U 24" x 36"
U Dual Gray :2_1,1r 36" x 36"
U Dual Brown U 36" x 40" Loft ❑ 4' x 8' ❑ 4' x 10' ❑ 6' x 12' ❑ > $
U Weatherwood
U Harvard Slate Window Boxes ❑ Wood ❑ 18" Color $
X Charcoal Gray ❑ Vinyl ❑ 24" _
U U ❑ 36" -
Drip Edge: L N U B Grids: W U B Shutters ❑ Wood Cglpr $
Simile D oor Double Door Vi { + ^
Width c i " Width tic, i
Type 0 ` C, Type F - D ''j re,✓1 Sys ,-mot S $ 1 5 t
Transom Transom no f ie e $ — 3 y -s-
Grids. U W U B Grids: U W U B cI�td 0,,1 , )ry f 1 ( - 1 CA 0)
ax b b p ++� (PT) $
i Hinges: U Std. U Strap Hinges: gStd. U Strap , 0 c% i} c /►� 2.0,1, n 3 c 4 °L'4" ) x y c - b l d g (k p
sg ukxre. co /!`a -ts
(not t l a ppca) ❑ Site Preparation — pad size x (subject to site evaluation) $
3 Overwidth Road Permit Fee $ /o tiT
Loading Illustration (0 tit-%, kvtl 4s�" 1 'k ubtotal $ (.0, S V S
e Sales Tax $ y0 k • Sb
-0 I t� TOTAL $ l o, 9 5 i , Ste
_ ,__ ___ _ -_ _ _ –_ _ `_ T railer Truck V 5 i , Sb
� Deposit $ ,
C'` .---,--- •,• ' ✓--- Balance $ 3 . 5 0 0 . taU
.
3, .r 1 K l ,1 ` .^..
Cu for f Signature
- '•••`••• ••- ••� 1 d?%. I9 1 JU009L0Y mdy LO LU I 1 I I : U I
r. v1
NOTICE
L r NOTICE
.rte -
TO _r TO
EMPLOYEES
?' '4,100 EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617- 727 -4900 - httpJ /wwwamass gov /dia
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:
Teclmulo r Iastuauce Co.
NAME OF INSURANCE COMPANY
ADDRESS OF INSURANCE COMPANY
TB1+WC 2011 05/27/2011 - 05/27/2012
POLICY NUMBER EFFECTIVE DATES
Berkshire Insurance 31 Court St., (413)562 -3659
Group, Inc. Westfield, MA 01085
NAME OF INSURANCE AGENT ADDRESS PHONE #
Hometown Structure 627 Southampton Rd,
Westfield, MA 01085 (413)562 -7171
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
• The Commonwealth of Massachusetts
Department of Industrial Accidents
_; l Office of Investigations
600 Washington Street
•~ =" Boston, MA 02111
.,,,. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): ,1 � C " ° ' f
Address: 7 3 (,-' t 1< ,1 ," ,) i;
City /State /Zip: LO e S 1 J. /III b' c <S Phone #: y r3 Si ° - - i J /
Are you an employer? Check the appropriate box: Type of project (required):
1. Cel I am a employer with ` J 4. ❑ I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have 8. LI Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3. ❑ 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 12.111 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.� Other eiccc s 13 J,3 .
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: Bet k 5 k. s (,r
Policy # or Self -ins. Lic. #: T RE fi ILK i / Expiration Date:
Job Site Address: I / 9 "t'u ) r'� j' k ��' City /State /Zip: f , / 0 / 0 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.
Signature: 4 7141`"- Date: / d 7 -
Phone #: t1l3 Cry 1
)- J
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 #:
•
Massachusetts - Department of Public Safety
• - Board of Building Regulations arid Standards
Construction Supervisor License
License: CS 98186
• .
ANDREW KURTZ ^t
295 BROMLEY RD 14:
`
HUNTINGTON, MA 01050 ' °,, ,
° — ---- ...... Expiration: 8/3/2013
( •nnu,i,ci,mer Tr#: 20132 -
•
V ��Tif/� / ,4 -I / I ' irI
t i ilitlIN :1 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.
j j Address J Renewal (_ I Employment I __ Lost Card
DPS -CA1 Cr 50M- 04/04- G101216
•
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL) (5 ` 3 $, 3 _ ? / 1
License Number Expiration Date
Name of CSL- Holder
r List CSL Type (see below)
Addre.ss � Type Description
/
(tmet4.to L U Unrestricted (up to 35,000 Cu. Ft.)
R Restricted 1 &2 Family Dwelling
Signature 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 Registered Home Improvement Contractor (HIC) ) � j
5 1n, rc
HIC Company Name or HIC Registrant Name `�` a'S Registration Number
Ir } 7 `jt _ .rh •►?110. r /:c_ 44.),: 1 . c � I ti7�
• Address 7 S `� r t'�
( % lam. `�. ' S �c d ` I 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 ib' No ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR
" TRACTOR APPLIES FOR BUILDING PERMIT
I, � Ok.� C. �-/C� it 'V • , as Owner of the subject property hereby
authorize .^`E iry c 'ti .. to act on my behalf, in all matters
relativ: to work authorized by this building permit application.
_Sig of Owner 41111 Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
07%1 .4: + ) ``) ff c v. �� , 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. M
Print Name � 9 3-2- j / D
(i
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.) YO (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 R-- Open
3. "Total Project Square Footage" may be substituted for "Total Project Cost"
I
1
RECEIVED
6, - 4 2011 he Commonwealth of Massachusetts
Bo. d of Building Regulations and Standards FOR
u . efts State Building Code, 780 CMR, 7th edition MUNICIPALITY
USE
tjon To Construct, Repair, Renovate Or Demolish a Revised January
One- or Two - Family Dwelling 1, 2008
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature:
Building Commissioner/ Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Pr y Address: m p- 2 Assessors Map & Parcel Numbers
1.1a Is this an accepted street? E yes X no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
i -es, ,i:u► 58, oeo ?q' 4/_.
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
--56 - At" ` /- L. R , 52 = 3 d C t.■ / 9 .
1.6 Water Supply: (M.G.L c. 40, §54) 1.7 Flood Zone Inform ion: 1.8 Sewage Disposal System:
Public ��/r,, Private ❑ Zone: _ Outside Flood Zone? Municipal Jrr On site disposal system ❑
�t' / Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner' of Recor
"John ( . (', - € f 1/1 4...';'A in of S1-. ,F /o;-<0. , in 71
Address -
Name (P 'nt) �. for Service:
a _ t// 3- ' Y - &JV3
Signat i• - ' 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. $ Number of Units Other ❑ Specify:
Brief Description of Proposed Work 4 i ti, °+ 1 0 r - S�''t 1 it S to x ) c'
( cxyso,y k3 /
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ ( Sh 5 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑ Total Project Cost (Item 6) x multiplier x
3. Plumbing $ __ 2. Other Fees: $
4. Mechanical (HVAC) $ _ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
5 �, �_ Check No. Check Amount 4 Cash Amount:
6. Total Project Cost: $ (_^ f1 Paid in nil fl flntctanriina Ralanre Tine•
.
■
File # BP- 2012 -0329
APPLICANT /CONTACT PERSON DOHERTY JOHN C TRUSTEE OF THE DOHERTY NORTH MAPLE
TRUST ✓
ADDRESS/PHONE 119 NORTH MAPLE ST FLORENCE (413) 584 -0143 0 \A® Et iSk °
PROPERTY LOCATION 119 NORTH MAPLE ST
MAP 17A PARCEL 209 001 ZONE URA(17)/URB(83) / �(\
THIS SECTION FOR OFFICIAL USE ONLY: `S )
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ��((
Fee Paid ? 1 ! S I OE LNG
Typeof Construction: REPLACE SHED W/12 X 20 51.16h, (
New Construction F ago ;An EAft PODPSCP1 Ll NE
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 98186
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFRRMATION 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 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
N/
Signature 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.
•
119 NORTH MAPLE ST BP- 2012 -0329
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A - 209 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- 2012 -0329
Project # JS- 2012- 000538
Est. Cost: $6505.00
Fee: $48.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOMETOWN STRUCTURES 98186
Lot Size(sq. ft.): 44431.20 Owner: DOHERTY JOHN C TRUSTEE OF THE DOHERTY NORTH MAPLE TRUST
Zoning: URA(17)/URB(83)/ Applicant: DOHERTY JOHN C TRUSTEE OF THE DOHERTY NORTH
MAPLE TRUST
AT: 119 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
119 NORTH MAPLE ST (413) 584 -0143 () WC
FLORENCEMA01062 ISSUED ON:10/24/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE SHED W/12 X 20
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 10/24/2011 0:00:00 $48.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
Ii.E