23C-098 (11) BP-202 1-2083
167 BAKER HILL RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
23C-098-001 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-2021-2083 PERMISSION IS HEREBY GRANTED TO:
Project# SHED Contractor: License:
Est. Cost: 9129 HOMETOWN STRUCTURES 108846
Const.Class: Exp.Date:03/24/2023
Use Group: Owner: DIETZ, ROBERT S. & LISA M.
Lot Size (sq.ft.)
Zoning: URB Applicant: HOMETOWN STRUCTURES
Applicant Address Phone: Insurance:
627 SOUTHAMPTON RD AWC40070284592020A
WESTFIELD, MA 01085
ISSUED ON:11/01/2021
TO PERFORM THE FOLLOWING WORK:
12X20 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:
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.
Signature:
Fees Paid: $48.00
212 Main Street, Phone(413) 587-1240,Fax:(413)587-1272
Office of the Building Commissioner
Z -0K
File #BP-2021-2083
APPLICANT/CONTACT PERSON:HOMETOWN STRUCTURES
627 SOUTHAMPTON RD WESTFIELD, MA 01085
PROPERTY LOCATION 167 BAKER HILL RD
MAP:LOT 23C-098-001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Building Permit Filled out
Fee Paid $48.00
Type of Construction: I2X20 SHED1.3.,(/)
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
INJ'ORMATION PRESENTED:
X 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 '
tf' ' ► i , I0 a`C1 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 standards of MGL 40A.Contact Office of
Planning&Development for more information.
RECEIVED
The Commonwealth of Massachus s OCT 2 2 20�1 FO
Board of Building Regulations and Standards C ITY
Massachusetts State Building Code, 78 C I. US
bFPr C
Building Permit Application To Construct,Repair,Re ate(: d 4 hJ Pic'Nged ar 2011
7777
One-or Two-Family Dwelling " MA 01060
This Section For Official Use Only
Building Permit Number: 60—A,t Rn $3 Date Applied:
L ; t ; ,2 ,�• is . . 1)4 al
Building Official(Print Name) Signature ' l
SECTION 1:SITE INFORMATION
1.1 Propertx Address: 1.2 Assessors Map&Parcel Numbers
hp &ker )l:ll Koad, Flo/once 23C• OR$
1.1 a Is this an accepted street?yes V no Map Number Parcel Number
1.3It Zoning Information: 1.4 Property Dimensions:
/01 8osk6 2 go
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
I IS-' LSV/,(202' 107
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Informs on: 1.8 Sewage Disposal System:
Zone: AQ Outside Flood one?
Public Private❑ Check if yes Municipal l�On site disposal system 0
SECTION 2: PROPERTY OWNERSHIP1
2.1 Owner'of Record:
Rol,era S,cod L 1's1.? i►1. 12•c--z po ten Ce, IiA 0/0 (02
Name(Print) ,State,ZIP
i(07 iguker Ill Road 2102-416,- 52o ('scli'e+z Qgqma'l.Com
No.and Street Telephone EmairAddress
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. II Number of Units Other 0 Specify:
Brief Description of Proposed Work': ae I,'vcr of rrc-u.SErni)Ind /2 A-20 de+a coed
accessory r+r�.cltir( (SAedj
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 9 )29.65 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ -...---- ❑Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ — 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees:
Check Nod 3 eck Am unt: A Amount:
6. Total Project Cost: $ 9 1 25, 6 0 Paid in Full ❑Outs g Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Joseph A C S- 1D�sS�I(� 3-2y-2c�23
k✓r iZ License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) (1
SOS Aihilcrst koQd
No.and Street Type Description
Gran 6 �A .23 U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,SWe,ZIP
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
2-7/7/ jocQhorv-fottii1S oc-I„n.i.coin I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) I 5-C1772 S-2(P-22
NoML4o G✓n S'rrv'..-4ure_s HIC Registration Number Expiration Date
HICompany Name or HIC Registrant Name
CP27 SOV41 (2Nte40n oct darv,n C)hothe+oivnS}ri,cIv(es.Cte1
No.and,StreetEmail address
,r'4 OiDS5S 1113-S-62- 717 I
City/Town,State,LIP 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 No . ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the • ..erty, ' - eby authorize NO mL71 o Curl S"fry c1vfc S
to act on ... .eh. in all matt rs rel. ive to work authorized by this building permit application.
+ . oc� eZ&
• �� "e(Electronic S.•. •tore) Date
' TION 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.
lu - ly. ? ha/
Print Owner' or Authorized is 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 90 (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"
..ommonwealth of Massachusetts '
1,..r Division of Professional Licensure
&oard of Building Regulations and Standards
Cons = 4 , ttO ry cor
F
CS-108846 88d �cpires: 03I24/2023
JOSEPH A K tTZ
505 AMHERS'J ROAD',:
GRANBY MA 10 p�, , .;.
7/�L '
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: LLC
Registration: 159772
HOMETOWN STRUCTURES, LLC Expiration: 05/26/2022
627 SOUTHAMPTON RD
WESTFIELD,MA 01085
Update Address and Return Card.
SCA 1 0 20M•05/17
Office of Consumer Affalh&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:LLC before the expiration date. If found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
159772 05/26/2022 1000 Washington Street -Suite 710
HOMETOWN STRUCTURES,LLC Boston,MA 02118
ANDREW KURTZ
627 SOUTHAMPTON RD CG '4/4.
WESTFIELD,MA 01085 Undersecretary Not valid without signature
•
The Commonwealth of Massachusetts
11 !l, Department of Industrial Accidents
=5 1=
r _;eial= 1 Congress Street, Suite 100
'';. i="•i E Boston,MA 02114-2017
,= www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
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):
1.0 I am a employer with 20 employees(full and/or part-time).* 7. 0 New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in
8. El Remodeling
any capacity.[No workers'comp.insurance required.]
3.0 I am a homeowner doing all work myself. [No workers'comp.insurance required.]'
9. ❑Demolition
10 ❑ Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.1:Electrical repairs or additions
proprietors with no employees.
12.❑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.
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c.
14.El Other accessory building
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:Berkshire Insurance Group
Policy#or Self-ins.Lic.#:AWC-400-7028459-2020A Expiration Date: 11/27/2021
Job Site Address: 167 Baker Hill Road City/State/Zip: Florence, MA 01062
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 certi y under the pains and penalties of perjury that the information provided above is true and correct.
Signature: 3'� Date: /0 - /3- O? I
Phone#:413- 62-7171
1
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
A.I.M. Mutual Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800) 876-2765 NCCI NO 26158
POLICY NO. AWC-400-7028459-2020A
PRIOR NO. AWC-400-7028459-2019A1
ITEM
1. The Insured: Hometown Stuctures LLC
DBA:
Mailing address: 627 Southampton Road FEIN:*"-***6332
Westfield, MA 01085-0000
Legal Entity Type: Limited Liability Company
Other workplaces not shown above: See Location
2. The policy period is from 11/27/2020 to-11/27/2021 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.
Premium Basis Rates
Code Estimated Per$100 Estimated
No. ! Total Annual Of Annual
Remuneration I Remuneration Premium
INTRA 000337067
INTER SE CLASS CODE SCHEDULE
Minimum Premium $500 Total Estimated Annual Premium $7,472
j GOV GOV Deposit Premium $7,719
STATE CLASS!
MA 2802 1 State Assessments/Surcharges
$7,042.00 x 3.5100% $247
This policy, including all endorsements,is hereby countersigned by �' - ` 11/20/2020
Authorized Signature Date
Service Office: Berkshire Insurance Group Inc
54 Third Avenue P 0 Box 4889
Burlington MA 01803 Pittsfield, MA 01202
WC 00 00 01 A(7-11)
Includes copyrighted material of the National Council on Compensation Insurance,
used with Its permission.
Coverage Is Provided In: Policy Number:
A„ ', Liberty Ohio Security Insurance Company BKS (21) 58 18 94 60
' Mutual. Policy Period:
INSURANCE From 12/01/2020 To 12/01/2021
12:01 am Standard Time
Commercial General Liability at Insured Mailing Location
Declarations
Basis:Occurrence
Named Insured Agent
HOMETOWN STRUCTURES LLC (866) 636-0244
BERKSHIRE INSURANCE GROUP INC -
WESTFIELD MA
SUMMARY OF LIMITS AND CHARGES
Commercial DESCRIPTION LIMIT
General Each Occurrence Limit 1,000,000
Liability Damage To Premises Rented To You Limit (Any One Premises) 100,000
Limits of
Insurance Medical Expense Limit (Any One Person) 15,000
Personal and Advertising Injury Limit 1,000,000
General Aggregate Limit (Other than Products - Completed Operations) 2,000,000
Products -Completed Operations Aggregate Limit 2,000,000
Explanation of DESCRIPTION PREMIUM
Charges General Liability Schedule Totals 14,347.00
Certified Acts of Terrorism Coverage 143.00
Total Advance Charges: $14,490.00
Note: This is not a bill
To report a claim,call your Agent or 1-844-325-2467
DS70220108
10/09/20 58189460 POLSVCS 450 PCXOPPNO INSURED COPY 000466 PAGE 71 OF 264
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: 2 3 C LOT: oq
LOT SIZE: I, c re s
REAR LOT DIMENSION: 2 Lf 0
REAR YARD /
SIDE YARD SO e a 90 ch e 'IDE YARD 2_D Zr
61S 01 1CS rarer
(,v e`I 1\ Se-1 J3 /J
FRONT SETBACK 1
FRONTAGE 2 Q '
Robert Sa dlisa N%
'Dietz
018
Address: l61 Baker
a V-A.*d\\Road
Vtorence,t`
Z3C.p98,p01
P\D paxcet'.
Tv\ap ti
gook&.page a
Zone. 1.g5
Ades' sewer s,
INA
,NateC and Sew
ua,c�pa1 cl
CO
280'
it
M
N
C �r t,
N
240,
City of Northampton
t.T MP O
Massachusetts
? � t DEPARTMENT OF BUILDING INSPECTIONS
1ordi � 212 Main Street • Municipal Building � �ee05 �
Northampton, MA 01060 •r:rNw 10`�J
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: LA - dd C-r (plumes der Service)
The debris will be transported by:
Name of Hauler: (J) 4.--C d" Recycif'nj
Signature of Applicant: Date: 6 /3 ) I
30-year architectural 2 x 4 rafters 16" on
shingles over 1/2" CDX center with collar
plywood roof sheetin: ties 4' on center
VP
ifr
4 v. - „,, ,
, .,, .,
exclusive detailing, n, I, r14 .' -,,,
painted eaves, x
and wood corners
loiskroilk7 --,, ‘ " '' double 2 x 4 top wa
F b t,
4 $ 40P Iplate, 2 x 4 wall stuc
double 2x6
I 16" on center
header over doors gc
lo, Ill
pressure treated floor
5/8" DuraTemp T1-11 fastened with system, 4 x 4 rails, joists 12"
4
galvanized nails, exterior acrylic on center, 5/8" plywood
latex paint - or 1/2" CDX with vinyl
Hometown Structures Invoice
627 Southampton Road
Westfield, MA 01085
(413) 562-7171 Invoice: INV-01086
Mil 1
r
www.hometownstructures.com Date: 10/13/2021
Lead Time: 6-7 weeks
—Structure Layout (not to scale) Ship To:
Custom Built Assembled Bob And Lisa Dietz
167 Baker Hill Road
Wood Shed Florence, MA 01062
Keystone
Dutch Colonial (262) 416 8520
rsdietz@gmail.com
12x20 L—J U
Colors Types Description Qty Rate Amount Tax
Siding TBD Building 8,005.00
Roof Base Keystone Dutch Colonial 12 x 20 (included)
Drip edge Floor 2x4 Joists, spaced every 12" (included) V
Trim Siding Wood T1-11 Siding (included) V
Corners Roof Architectural Shingles (included)
Doors Doors&Windows 550.00
Windows Doors Wooden Double Door T-D 1 400.00 400.00
Windows Standard Window 24 x 36 2 75.00 150.00 -V-
Services 1,068.00
Notes: Site Prep Stone pad for 12 x 20 structure 1 980.00 980.00 --
Delivery Overwidth Permit 1 40.00 40.00 --
Permit Building Permit 1 48.00 48.00 --
Subtotal $9,623.00
6.25% $534.69
Customer signature Total $10,157.69
Deposit $3,500.00
gaizAr _Malt- Balance $6,657.69
Sales Person:Darvin Martin