42-062 (3) BP-2021-2019
15 GLENDALE RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
42-062-001 CITY OF NORTHAMPTON
Permit: Exterior Res
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2021-2019 PERMISSION IS HEREBY GRANTED TO:
Project# SLIDER Contractor: License:
Est. Cost: 3000 DAVID GARSTKA BUILDERS LLC 160765031153
Const.Class: Exp.Date:08/22/202208/15/2023
Use Group: Owner: MOFFETT BARBARA A& DAVID J MOFFETT
Lot Size (sq.ft.)
Zoning: WSP Applicant: DAVID GARSTKA BUILDERS LLC
Applicant Address Phone: Insurance:
41 COLD SPRING RD (413)695-0898 0 0762N358
SOUTHAMPTON, MA 01073
ISSUED ON:10/14/2021
TO PERFORM THE FOLLOWING WORK:
REPLACE SLIDER DOOR
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: 10 • lif• Tlf,,kv
Fees Paid: $40.00
'212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
41/11
' 1
The Commonwealth of Massachusetts C41 /f
14):e: Board of Building Regulations and Stan.. ds Op- -•40
•
Massachusetts State.Building Code,780 r MR 1 �'�� I
U
Building Permit Application To Construct,Repair,R- •vatk4) :a olish a ised ar 2111
r
-Family
ing
/44
One-his Section For Official1U e Only �ogTti Mn�oi,,'MvS,o
Building Permit Number: (30-A/-. ZO► T Date Applied: 414 o oe°Ats
k' )I/J /oss ,1///7 i- ly-ZOZ/
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.��pelddr _ /� , 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?fyes' /✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
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
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: — Outside Flood Zone? Municipal 0 On site disposal system ❑
Check if yes❑
/ f, • ySEECTION 2: PROPERTY OWNERSHIP'
2.118 1(i) diii)V /a )'te'e /1147 '//" &
Name Print) City,State,ZIP
i(S64 .1/e 461, of/3 -07 /,#7 hete/ro.4erJf7Q7,4, ee.c7
No.and Street Telephone Email Address
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. 0 Number of Units Other ❑ Specify:
Ilmermemynk of Proposed o_ geG -e_ S(ii'0 fig POO 0----( d t,-7 4 '
'Thoc.LC� / u.-0 0- FHcim . .0/0
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
411.11.111111 $ 3 dtrz.) 1. Building Permit Fee: $ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Feraq ii 40
�� Check No.!l Check Amount:
6. Total Project o i r1'�, 0 Paid in Full 0 Outstanding Balance Due:
City of Northampton
�1,7.1
,.,.
Massachusetts
� ,i .
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building ,,.
Northampton, MA 01060
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS,
DOORS,ROOFS,RENOVATIONS,ROOF MOUNTED SOLAR,ETC.
1. Building Permit Application signed by legal owner and filled out
by owner or authorized agent.
2. One set of plans and specifications of proposed work(Digital and hard copy).
3. Construction Debris Affidavit filled out and signed by applicant.
4. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
5. Contractors must supply a copy CSL, HIC, and proof of Liability Insurance.
6. Energy Conservation Compliance Certificate (new /replacement windows).
7. Home owner's License Exemption Form (if applicable).
8. Note any Special Permit requirements (if applicable).
9. Energy Code—all new construction(Gut/Rehab) requires a HERS Rater Affidavit
10. Please provide the appropriate fee in the form of a check made payable to: The City of
Northampton.
•
41
SECTION 5: CONSTRUCTION SERVICES
togi6Construction Supervisor License(CSL) 61 3ll.(17 ir/rA3
�� sDlJ(//
- -- 77 t License Number Expiration Date
Name of CSL Hold
N' �, ' List CSL Type(see below)
No.and Street TY Description
�d ri !/��- dlc�J 3 L/(�) Unrestricted(Buildings up to 35,000 cu.ft.)
/ R Restricted 1&2 Family Dwelling
City/Town,State,Z M Masonry
RC Roofing Covering
WS Window and Siding
n /� �/ SF Solid Fuel Burning Appliances
G1i.3'6 5'S'd of/ i�zrii Ye -si 2 I Insulation
Telephone Email address D Demolition
5.2 registered me Improvement Conti c or(HIC) /ODTlos 0,72.7—C f3v: s c 19��i s� HIC Registration Number Exp Date
HamCoee•-r ...•e ••-•r Re str Name (.0444 Q 1""
=�C,(' � 7 ma's ��eG�-�
Nod.$Ir4e s t, L ? ix D/0,73 6 r r D p fil Email address
City/Town, State,ZIP �` 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 I9— No .❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to orized by this building permit application.
v/CI . /ye /.,ad-Print Owner's Name(Electronic Signature Date
• SECTION 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/ 1„e .i d accurate o the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name Electro;,(i 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.) (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"
r:-L.\... The Commonwealth of Massachusetts
Department of Industrial Accidents
,1-1 I Congress Street,Suite 100
Boston, MA 02114-2017 r,
woov.mass.govidia
%%otters'Compensation Insurance Affidavit:Builders("untractorsiEleetriciansiPlumbers.
in BE F11.E1)'1111°H THE PIH.11111 LNG AETHORITY.
Applicant Information Please Print Lettibis
Name trlusiticss,Organizationlindividual); )Pt(.'; a 64P-C-7/C°1' U Or 6-P&-,-
Address: z-ft c.ze _s,,,,-,i
, tecp
City/State/Zip: 7-57e),J7-4 /MO-0/673 Phone#: (--//_7-4-
. .. . . .
Are you an ClIntfill'%tr:*(lick the appropriate hot; " Ty.pe of project(required):
1.0 i am a,...mpio2.,-; ..,:th ert47,10.2.,:eh t fult airier part.timel" 7. 0 New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. cj Remodeling
an capiiiI4:1[Y[Nu tirri:cutup imurazna: requartd.J
. El30 I am a horneviwner doing all wort naysclf.[No workers'comp.imoratice requinid 9 Demolition
i"
i 0 El Building addition
4.0 1 am a tiotne~to•and will be hiring contractors to i-onduct all work on rny property, I swill
ensure tha all isontracturs either liak,e vi.inkerA"...venix..11.SZMOtt trisuranet or Arc*ole 11.0 Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
.5.ar(am a general contractor and I have hired the sub-curstrictors listed on tic anaithed sheet_
These subon-ctrsetors Iss ni ue eployees and have workers'comp.tri 13.[: Roof repairs
surani-e;
14.Etr)ther
' 6.0 Vie are a corporatism and as officers have exercised their right of exemption per SIIGL c.
1.2_,§It a t.,and ue have no employees.[No workers comp.insurance required./
'Any appticiutt that checks box its must also fill out the section below stiowing their Workers'compensation policy information..
Horneewiscrs who subtnit this affidavit indicating they are doing art work and then hire outside emit:me-tors must submit a new affidavit M4111.21.101;such.
lContraetins that check this box must attached an aiklitiunal sheet showing the name of the stiti-ser- stractors mut mite whether or not those entities have
omplo‘ee, If the ub-euntraetces 1%,,..,11:r1o.,,ei....thcy must pros isle then worlsers'comp.policy maitter
. _
I urn an employer that is providing workers'compensation insurance for my employees. Belo PV iA the policy and job,Nile
information.
Insurance Company Nan : -7g---n e/ed 'P..; :17._/ci....r-e"/--tsi-o.-c,_
—
_
Policy#or Sit-ins.Lic.#: 076 z.... /k1,..5- Expiration
Job Site Address: 1 S 6-(t.."--,p.-4.. "--, ( /Ae-i-e-e City/State'Zip:
Attach a copy of the workers'compensation path!, declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under hltiL c. 152,§25A is a criminal violation punishable by a tine up to$1,500.00
andlor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to$250.00 a
day against the violator.A copy of till h statement may be forwarded to the Office of Investigations of the DIA for insuran.c
coverage verification.
I do hereby certif.,'uffiller the pains and penalties of perimy[hut the information provided above iN true and current
dSignatup.:( ....,.-------/ Date. /67///e.-/
Phone&. e-il-7— 6 '-'_t- - o Ps/
1 Official use onlr. Do not is in ilu urea,to he completed by city or town official
: .
I'ity or Town: Permit/License#
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.Ckyrrown(lerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
1 !
Conflict Person: Phone*:
City of Northampton
0
} '* Massachusetts .
DEPARTMENT OF BUILDING INSPECTIONS <, ?
212 Main Street • Municipal Building
Northampton, MA 01060 .11V ?,� '
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of
in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility: GPI -��
7
The debris will be transported by:
Name of Hauler: /4/it lug / Lac
Signature of Applicant: Date: /U4/
41.
City of Northampton
Massachusetts
� � DEPARTMENT OF BUILDING INSPECTIONS S
212 Main Street • Municipal Building
Northampton, MA 0106044 }i;$
J 'HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
L -;
� CY J• "76/j`fr (insert full legal name), born_(insert
month, day,year), hereby depose and state the following:
1. I am seeking a building permit pursuant to the homeowners'ex ption to the permit requirements of the
Massachusetts State Building Code, codified at 780 CMR 1 .R5.1.3.1, in connection with a project or
work on a parcel of land to which I hold legal title.
2. I am not engaged in, and the project or work for witch I am seeking the aforementioned homeowners'
exemption, does not involve the field erection of i y1nufactured buildings constructed in accordance with
780 CMR 110.R3.
3. I qualify under the State Building Code'zsfinition of"homeowner"as defined at 780 CMR 110.R5.1.2:
Person(s) who owns a parcel o and on which he/she resides or intends to reside, on which
there is, or is intended to . a one-or two-family dwelling, attached or detached structures
accessory to such use and/,r r farm structures. A person who constructs more than one home in
a two-year period shall be considered a home owner.
4. I do not hold a valid 'ssachusetts construction supervision license and, except to the extent that I
qualify for and will a. de by the Massachusetts State Building Code's requirements for the supervision of
the project or work . my parcel, I am not engaged in construction supervision in connection with any
project or work nvolving construction, reconstruction, alteration, repair, removal or demolition
involving any tivity regulated by any provision of the Massachusetts State Building Code.
5. If I engage ' y other person or persons for hire in connection with the aforementioned project or work on
my parcel acknowledge that I am required to and will act as the supervisor for said project or work.
Signed und' • pains and penalties of perjury on this /d day of Q Q?(*bt' `j', 20 o41,101011011 -
(Signatu dr