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25C-166 (10) Office of"Consumer Affairs and Business Regulation 10 Park Plaza - Suite �170 Roston, 4lassachusetts 021 10 1 tome Improvement Contractor Registration Registration 150772 Type Ltd Liability Corporation Expiration 5/27/2014 Trft 228578 HOMETOWN STRUCTURES ANDREW KURTZ 627 SOUTHAMPTON RD WESTFIELD, MA 01085 Vpdaic Address and rcturn card.Mark reason hor chanec. Address Rrnew:d Lusr Card ��•� �la..achu>ctt.- Dcp:u'nncm ut•Public �af'cn Beard of Buildim:, ftcsulatinn.and tit:uulard. Construction Supervisor License License: CS 98186 AlF 'M ANDREW KURTZ 295 BROMLEY RD HUNTINGTON, MA 01050 Expiration: 8/3/2013 l ..nnni„i.an'' Trs: 20132 tN Cr t S f o-- C: w a J te CIO L"fG } l c. 7 4J 1 r— c r ti• r - ^ of . 41 -Almi Emomb- s A<4 1 r r 1� i s a. `s C _ ;` . a uwlllt t � NOTICE ' ;>= NOTICE TO `` O EMPLOYEES EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 - http://www.mass.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 in'uring with: T chnology Insurance Company NAME OF INSURANCE COMPANY 5800 Lombardo Center Cleveland OH 44131-2550 ADDRESS OF INSURANCE COMPANY TWC3321269 5/27/2012 to 5127/2013 POLICY NUMBER EFFECTIVE DATES Berkshire Insurance Group, Inc. PO Box 4889 Pittsfield MA 01202 413-562-3659 NAME 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 pry vided 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 th t the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER I HomuowN • STRUCTURES 627 Southampton Road Order Date _g" Westfield, MA 01085-1329 Estimated Completion Date (413)562-7171 Bill To Xmke;m Notes Address P b Orc kc rd Mr-t J- d Phone yb 7 5�_8'/1 Cell Phone# E-mail Address DuraTemp T1-11 ❑ ❑ Vinyl ❑ In-stock Display Shed 114 To Be Custom Built Body Color r-e-8 Body Color Trim Color L.Jk;` (_ Trim Color. White ❑ Delivered Fully Assembled (includes fascia&trim around doors and windows) (Includes fascia&trim around doors and windows) ❑ Modular ❑ Modular Door Color chi, C4 re-en Door Color Built On-site (Specify if trim on door is a different color)J Corners Corners "k i-0— SOFFIT CHOICE(For New England Style Only) Size X a ca SOFFIT CHOICE(For New England Style Only) ❑ Venting Vinyl White New England Series ❑ Solid DuraTemp T1-11 Body Color ❑ Venting Vinyl Brown ❑ Exposed Rafter Tails Body Color ❑ Keystone Series ,W Aluminum Strip Vent sodycoior Base Price $ ,')_0' _ style Akw_ 4` �s Door Adjustment $ Y Uy Code $ _51 Window Adjustment $ 100 Shingles Windows Ramp )('6'x 4' ❑ 5'x 4' ❑ 54"x 4' ❑ $ ❑ Dual Black ❑ 18"x 36" ❑ Earthtone Cedar ❑ 24"x 36" Loft ❑ 4'x 8' ❑ 4'x 10' ❑ 6'x 12' ❑ �u�$ Dual Gray y-" 30"x 36" ❑ Dual Brown ❑ 36"x 36" Window Boxes ❑ Wood ❑ 18" ❑ 30" $ ❑ Weatherwood _❑ 36"x 40" n, ❑ Vinyl ❑ 24" ❑ 36" ❑ Harvard Slate P� ❑ Charcoal Gray }rGns a+*+s Color ❑ 4-35 10,330 Shutters ❑ Wood Color/Detail P-11-1 $ Drip Edge: kW ❑B Grids: )"W ❑B ❑ Vinyl Single Door Double Door ^cu l 1 S* r--e_e'4.S z $ 3 Uf7 Width 31 Width to $ Type 1' Type T'E" Transom Transomot*w s read .✓`�" $ I► , Grids: A W ❑B Grids:`G W ❑B +-� NT Hinges: ❑Std. Strap Hinges: ❑Std. J(Strap Site Preparation-pad size_42]_X 0 5 (subject to site evaluation) $ I i .S- I)d Overwidth Road Permit Fee $ Y0. AT A a Loading Illustration Subtotal $ 3. (os 31.. Trailer Truck Sales Tax $ Y0 y (°9 9 TOTAL $ S`0 5 Y. 69 Deposit $ _ Balance $ CA stomei Sig atur O O O (D 00 LO ,,;I- O LO Qc) N LO O ISO, LO N T n� V) O CY) (� ` r 0j L N O CY) ti r**-- M O (C) I\ The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 kwwj Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly 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. ✓❑ I am a employer with 12 4. ❑ I am a general contractor and 1 6. ❑ New 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. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working or me in an capacity. employees and have workers' g Y 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.❑ 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 accessory buildin employees. [No workers' 13.0 Other ry 9 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:Berkshire Insurance Group Policy# or Self-ins.Lic. #:TWC3321269 Expiration Date:5/27/2013 Job Site Address:26 Orchard Street City/State/Zip:Northampton, MA 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 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 enalties ofperjury that the information provided above is true and correct. Si nature:=1 Date 3-13-13 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#: SECTION 8-CONSTRUCTION SERVICES 7 8.1 Licensed Construction Supervisor: Not Applicable ❑ p Name of License Holder: License Number Address Expiration Date Signature J Telephone 9.Realstered Home Improvement Contractor: Not Applicable ❑ic Company Name Registration Number 6 a-� Ste, >���,��� (��,, �es�F;� I�. /)d oloeg S - ado/y Address Expiration Date / ill _tea I� Telephone 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....... 110 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 ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors E] Accessory Bldg. tz Demolition ❑ New Signs [❑] Decks [[Z] Siding[❑] Other[E3] Brief Description of Propposed Work: C_e,n Of Alteration of existing bedroom Yes X No Adding new bedroom Yes k No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet &a.if New house 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 I, R as Owner of the subject property hereby authorize "e 'yJc-i-ut e S to act half, in al(matfers lati a to+rk authorized by this building permit application. Sig of Owne Dale as Owner uthorized gent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge nd belief. Signed under the/I__ /1( pains and penalties of perjury. G�'n / ' 1"r tl)n Print Name , / - ) 1 - )3 Signature of ne/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 Frontage Setbacks Front f l y IS Side L: R: L: cQ R: t1 Rear L/ Building Height Cl Bldg. Square Footage % �,; Open Space Footage (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW YES Q IF YES, date issued:' IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T 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 Q 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 Q NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. pity of Northampton 42013 wilding Department rc'F DEPT 212 Main Street 3h.E z V. � t Room 1OO Northampton, MA 01060 , u a � tal phone 413-587-1240 Fax 413-587-1272 � f 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 Az- Map Lot Unit `Q V' Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: le un�' > r7 1!� lJy� C_�C/d S .'..i A)Ur+i1��v�p'�n, Name(P'qt) .1 } Current M 'ling Address: l 'ling �' ✓' Telephone ign re 2.2 Authorized Agent: Name(Print) Current Mailing Address: .LQt_, V13- Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 7 -7 S` (a)Building Permit Fee 7 O 2. Electrical (b)Estimated Total Cost of � Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 10 170' 6. Total=(1 +2+3+4+5) Check Number (J YO-7 This Section For Official Use Only Building ermit Number: Date g Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2013-0828 �G / ✓��2e� �Q/�" - jC— - is APPLICANT/CONTACT PERSON HOMETOWN STRUCTURES Pa ADDRESS/PHONE 627 SOUTHAMPTON RD WESTFIELD (413)562-7171 —� PROPERTY LOCATION 26 ORCHARD ST MAP 25C PARCEL 166 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid / � 1 - Typeof Construction: CONSTRUCT 2 STORY 18 X 22 ACCESSORY BUILDING`-- QJTFA(- I New Construction -Fo 66 Non Structural interior renovations � N 4 Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 98186 3 sets of Plans/Plot Plan a THE FOLLOWING ACTION HAS BEEN T INFq�2ATION PRESENTED: ✓Approved proved Additional permits require PLANNING BOARD PERMIT REQU Intermediate Project: Site Plan) (mil yy N� Major Project: Site Plan. ZONING BOARD PERMIT REQUIR] Finding Special Permit v anance- 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 Ehn Street Commission Permit DPW Storm Water Management Demolition Delay Signature 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.