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
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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 $
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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.