23D-107 (2) Massachusetts - Department of Public Safet■
• - Board of Building Regulations and Standards
Construction Supervisor License
License: CS 98186
•
ANDREW KURTZ
295 BROMLEY RD
HUNTINGTON, MA 01050
- __.---y _..-...,e Expiration: 8/3/2013
( ntumi, ion rr Tr#: 20132
•
...0 -62.,.../4 , 4 , 4 ' I 4
"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 Address l Renewal ( I Employment (__, Lost Card
DPS -cm 0 50M- 04/04- G101216
•
The Commonwealth of Massachusetts
Department of Industrial Accidents
,a'pi; Office of Investigations
600 Washington Street
- "` Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information ii Please Print Legibly
Name ( Business /Organization /Individual): MQ.Avw n S - i c + res
Address: LP 2 1 S R J,
City /State /Zip: Li - + 1 c mj 0 /0'S Phone #: `/ /3 - a "7/ "7 /
Are you an employer? Check the appropriate box: Type of project (required):
1. ® I am a employer with 4. n I am a general contractor and I
employees (full and /or part- time).* have hired the sub - contractors 6. 111 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. ❑ Demolition
working for me in any capacity. employees and have workers'
9. n Building addition
[No workers' comp. insurance comp. insurance.*
required.] 5. n We are a corporation and its 10.0 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.E Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.® Other ci c(e 55 pr y 6 li
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
r 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. nn
Insurance Company Name: k.S) I/7 co,p
Policy # or Self -ins. Lic. #: T 1 + L C ?oil Expiration Date: S a 7' 0
Job Site Address: .5 Yg Fct S i E I i'VN S 4 , City /State /Zip: A o ( - 4 k b.► 10/9 O tU too
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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: 0 Date: / -
Phone #: y / 3 SZKY a - 71 ,
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit /License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
SE TION 5: CONSTRUCTION SERVICES
5.1 'Licensed Construction-Su " rvis r (CSL)
C ' S9$ / 81 ' - 20/ 3
License Number Expiration Date
Nam of CSL- Holder List CSL Type (see below) U
Address / S13 Type Description
U Unrestricted (up to 35,000 Cu. Ft.)
(/ Restricted 1&2 Family Dwelling
•
Signature M Masonry Only
5 (O 7 / ' I RC _ Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improve rent Contractor (HIC) 7 7
S re
HIC Company Name or HIC Registrant Name ' l / /)) Q Registration Number
d SU «/h � i/
'Icy'? 1 G� WeST��C( /)/
Addres I D tq&'S d (9C) I a
�, - 7/'7 / 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 ti No ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Cc, w r. Co l i c e /OursiA3 d 1 pp ` . k c J , as Owner of the subject property hereby
authorize H-0 • —R. Nu+n S{ i o1'. re s to act on my behalf, in all matters
relative to work authorized by this s bbuilding permit application.
/17 ((a___
Signature of Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
:1 S /'e s , 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. 1
Gin �y� n / c,r4 .�
Print Name 1 ✓ a I — c o /
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.) o (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"
RECEIVE°
MAR — 7 2012
The Commonwealth of Massachusetts
'! �1. I Board of Building Regulations and Standards ' Seem 01 ro R
x\ , Massachusetts State Building Code, 780 CMR, 7 e ition USE LfrY
�.
Building Permit Application 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 Propert Address: 1 �� 1.2 Assessors Map & Parcel Numbers
SYB" ['/M 51 4),,,rfl.a-,ri-,,
1. la Is t s an accepted street? yes IC no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
11x0l D OU
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
1S 3o' Y ' + . So / f: Co' y 1 SOo' 1 /-
1.6 Water Supply: (M.G.L c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public V Private ❑ Zone: Outside Flood Zone? Municipal jaf On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner' of Record: /� C ^ ' q
Ca L';' ; *5c. �1_,IS:, �KI�c � s 7 O G 3i-
Eci.S Fi, , /JLr/ 1c�,il.,� 'tog
Name (P I' I'M) ,c �� Address for Service: p j C� Lob
� y Sno - 3 ? SA 3
Signature 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. 1}ii Number of Units Other ❑ Specify:
Brief Description of Proposed Work - I ; ''&r-'1 ( --J I 8- x d c; G c Le s S _/ 6)`L.3.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ ID G I U 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ 3
❑ Total Project Cost (Item 6) x multiplier x
3. Plumbing $ - 2. Other Fees: $
4. Mechanical (HVAC) $ — List:
5. Mechanical (Fire �-
Suppression) $ Total All Fees: $ ( s' i
(O g / v 4, Check No. beck Amount: Cash Amount:
6. Total Project Cost: $ i ❑ Paid in Full ❑ Outstanding Balance Due:
,-
. R01/6 �s�
File # BP- 2012 -0782 W .6) 1\1461 )3
APPLICANT /CONTACT PERSON HOMETOWN STRUCTURES i - 3C(111-
ADDRESS /PHONE 627 SOUTHAMPTON RD WESTFIELD (413) 562 -7171 ne, ' C " � ;�
, ` u
PROPERTY LOCATION 548 ELM ST 0 a i V 23D PARCEL 107 001 ZONE URB(100) / /WP ��
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out a / g
Fee Paid d56
Typeof Construction: ERECT 18 X 20 ACCESSORY BLDG
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or 98186
3 sets of Plans / Plot Plan
THE F LL OWING ta ACTION License HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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
c., -C t' 3 / Si nature of Buildin Official Date
Signature Building
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.
548 ELM ST BP- 2012 -0782
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23D - 107 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 # B P- 2012 -0782
Project # JS- 2012- 001368
Est. Cost: $10810.00
Fee: $72.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOMETOWN STRUCTURES 98186
Lot Size(sq. ft.): 53143.20 Owner: 548 ELM STREET LLC C/O 548 ELM ST OPERATING CO RE TAX DEPT
Zoning: URB(100)/WP(1)/ Applicant: HOMETOWN STRUCTURES
AT: 548 ELM ST
Applicant Address: Phone: Insurance:
627 SOUTHAMPTON RD (413) 562 -7171 WC
WESTFIELDMA01085 ISSUED ON:3/19/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: ERECT 18 X 20 ACCESSORY BLDG
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 3/19/2012 0:00:00 $72.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner