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o DEPARTMENT OP BUILDO\IG INSPECTION'S
212 Alain Street ' A'funicipal Building
Northampton, Mass. 01060
/ WOMCER'S COMTENSA'MN INSURA-NCE A1'MAVIT
(li ccuscc/pcnni flee)
V"Ith a principal place of business/residenc-e aat:
C' '7 400,417 .! -os--7
_�,,-�4,e- AA, (p,�0 n e
(507c-.Uc-i t)45(afr-/zj P)
do hereby certify, under [lie pa-ins and penalties of pedury, :hit
( ) I am an employer providi-ng t-he followins, worker's comoens ion cove 2^e or Ins
emplovecs worlang on tills job
(Lase-:=Coo=,) (Petit: Nu_atlxr) -- (r`;piruo t Date)
( ) I am a sole proprietor, general contractor or homeowner (ci cie oee) aDd have hired
the contractors listed below who have the foiloVvi_ng workef's coMDention policies:
(Nnmc of Cont:-acror) (Insumnc; Coinpany/Pouc Num!rr) (%_>:aira:.0 Datc)
(Name of Coo(Tactor) (ins mnc;, ampa-uy/Pone y NunLrr) (i:»u iion Date)
(Name of Contractor) (Iasuranc: CompaDyfpouc). Number) (Boir000 Date)
(Name of Contractor) (I_osZtlan Comrany/PoLicY Numbs) (L-xpiraiioo Date)
(toa.r3t ad?i�ocal rxcl if ncccu n t�cK Utz informi_i oo pertainins to n11 000-r.�on)
�am a sole proprietor and have no one wor4dng for me.
( ) I am.a home owner performing all the work myself.
NOTE:ply be twat t!,,�'L^_]c bomcoA rs wj>o employ pes.ons tv us I c-rr,au Cori:m_t d..c1L of
not m«c them In t]L.u eh the bornoawv,rvidet or oa the pvun ,zppurtcn r1 tb- z c c no(Ee�.By ocer:d_=to be
employ—unGc fixµa{Q s ax7 _tim Act(G Lt 52-,cs 1(5)�spgU=uioo by a homao%-D r for:GcS._or permit m:y ni&ooc the
Icirl ctnau of an employer under dto Workxet Cocapomtiioa Ad
I uadastxnd flat a copy of this r Lcmcat o y bo foc?,tio-d to tbo Dryuta rns of lod rrjd Al doa 01Lo of lrr ooc for the
°°v`z'bt�tf clioo and tlz t"-L t to Lo cult eovcTnsc tmdcr soc6oa 25 A of MG L 152 can Iced to the=poaitioa of aimiatl pcoz-wcs
000iiszing of a fine of up to S I.100.00 and/or of up to cot yt-if and cl i1 pca0jc3 in ttx form of a Stop Work Ord,Lod t
fim of S 100.00 t dsy tFpinst me
------------
For dcp=r —�j u�coly
�_... Pc=t Numbcr
MA Lot
Si�nahtn of Lt�scrlPcnTUucc e
tsed ERVICES
Construction Supervisor: Not Applicable ❑
� .
ame of License Holder: ��� �i -5' ' ®3 f"S-3
License Number
A dres Expiration Date
Signature Telephone
:n..... • e:t 'tr-„ ,.. YL -i T� � cam%
MMRMI � k (4;Et..°. . .m `E1 Not Applicable ❑
Z;//,d-')c C f9,,-' ' -5-1"S 06
Company Name Registration Number
eft s( SeP/Z f�``j 7�13zo 2
Address v Ex irati n Date
Telephone SZ 7'-C� .-7
SECTION.141-1NORKERS' 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.......V No...... ❑
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
J_aVqT1!0NS- ,..Q; PR.QRO$EQVQRK 4,heck,gffiapplic"I,
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
PI s Attached Roll ❑ - Sheet❑
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. Mascheck Energy Compliance form attached?
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-pW)j_'ER AUTHORIZATION -TO�BE COMP�,:>='t 1=D WHEN
b fNE 5 AQEI I"I"Cat CbNT.#*dtoR;AI'PLIES tO ,'BUILDING PERMIT
EM 0 as Owner of the subject property
L,Kereby authorize ST to act on
my b If, in all mattergs relative ork authorized by this building permit application.
e SIR
Signature o Owner Date QQ
as Owner/Authorized Agent
hereb declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print ame
Signature of Owner/Ag nt Date IL 0
Section 4:
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
VJS
4ntage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
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 DON'T KNOW_� YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page _ and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
f'
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413.587-1240 Fax 413.587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INF ORMATION ,
1.1 Property Address: tad '
�.
F
Etrrn Stplstrictr �a�d7lstc
t,
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
PZ �" f� s l 4 f 73v,�?s /�'� l
Name P ' t) Current ailing Address:
LY 4:4
nature Telephone
2. thorized A ent:
Name Print Current Mailing Address,
Signature Telephone
ACTION"3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official,Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total;.Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4 + 5)
l� Check Number
T "TW Sectidn For Official"Use Only'
Building Permit Number: ' Date"Issued:
iature
Building Comm issloner/I nspector of'Buildings Date
1261 BURTS PIT RD BP-2001-0038
CIS#: COMMONWEALTH OF MASSACHUSETTS
M.Block: 35 -081 CITY OF NORTHAMPTON
Lot: -001
Permit: Buildina
Category:roofing BUILDING PERMIT
Permit# BP-2001-0038
Project# JS-2001-0066
Est.Cost: $4100.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MAX T. GARSTKA & SONS BUILDERS 104109
Lot Size(sq.ft.): 19166.40 Owner LEOUIN RAYMOND A&HELEN P
Zoning,_SR Applicant: MAX T GARSTKA & SONS BUILDERS
AT. 1261 BURTS PIT RD
Applicant Address: Phone: Insurance:
41 COLD SPRING RD (413) 527-0574
SOUTHAMPTONMA01073 ISSUED ON:7112100 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & INSTALLED ROLLED ROOFING
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 7/12/00 0:00:00 2063 $25.00
r,
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo