30A-054 HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or hvo 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
home owner."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, to act as their own- construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires that the building department be called to
inspect work at various stages, which include foundation /footings (before backfill),
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform. work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
jermits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, /rj6 41.(,t,�,�. . derstand the above.
(Home owner /resident's signature r ' ting exemption)
I will call to schedule all required buildin_ spections necessary for the building permit
issued to me.
Date 447.
Address of work
location '-/'/ L- /f f, .7 t rr.
" ,...
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
• ---' rz...-...- ;
600 Washington Street
Boston, MA 02111
%...,....,- - , www.mass.gov/dia .
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legiblv
. .
Name (Business/Organization/Individual): 414,4 s. Ai4 p TkAnri 4. cireTrative, ..
Address: (44 i_ sr. „ -
City/State/Zip: FLogs4ce, AAA -0t(.. Phone.#: 1(2 *344 • 3774.
Are you an employer? Cheek the appropriate box: Type of project (required): /
1.0 I am a employer with 4.. 0 I am a general contractor and I
6. 0 New construction
have hired the sub-contractom
employees (fall ancVor part-time).*
listed on the attached sheet. 7. gi Remodeling
2. 0 I am a sole proprietor or partner-
These sub-contractors have
ship and have no e=ployee.s 8. 0 Demolition
employees_and have workers'
working for me m any capacity. 9 -0 Building a.cdit'iiiin
[No workers' wrap. insurance
required.] . 5. 0 We are a corporation and iis 10.0 -Electrical repairs or adcritions
3. Igl I am a homeowner doing all work officers have 4xercised their . 11.0 Phmabing repairs or additions .
myself [No workers' crimp. • right of exemption per MGL
12.0 Roof repairs . -
insurance required.] t ' c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp. ins= required.]
*Any applic:ant that checks box #1 must also fill out the section below shovving theirworkers corrpcasation policy informatiort.
t Homeowners who submit this affidavit indicating they am doing all work and then hire outside contractors must submit a new affidavit indicating such
IContractors that claPrle 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-coniractors have employees, they must provide their workei-s comp policy number. . .
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy andjob site
information. .
Insurance Company Name: • -
Policy # or Self-Ms. Lic. #: Expiration Date:
. ,
Job Site Address: City/State/Zip:'
Attach a copy of the worker?' compensation policy declaration page the policy number and expiration date).
Failure to secure coverage . as required bider Sectiiiii c 152 can lead to the imposition of Criminal Penalties of a
fine up to S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP ORDER and a line
_ .
of up to S250.00 a day against the violator. Be advised that a copy of dais statement n3ay be forwarded to the Of6ce of
Hitiiitions &the DIA for insurance eaveraieirerificatioa.
_,------ . -- -- ---- -
_ fdo herefrycertib under pains an d penalties of erjray at the information providerraboverue.and_cop:ert _
i
Signatne: • Date: 6 ./7. /6
.../(,,
Phone ik 4s.30.3774 ' - - •
. . ... ........,............
- Official use only. Do not write in this tirea, to be cipleted by city or town
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
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
B: Reaietere i.Heme= lliiiir'iifrern 6 g i tiiiitoe g. n ,: w � j r: . ; - Not Applicable ❑
Company Name Registration Number
Address Expiration Date
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 ❑ No ❑
�Y $ M
11., -.H, l wn
m OeriExemp Ins
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 1083.5.1.
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
g �Jt/� oning Laws and State o ass efts General Laws Annotated.
Homeowner Signature , ` ede...._
SECTION 5- DESCRIPTION. OF PROPOSED WORK (check all applicable)
New House [j Addition ❑ Replacement Windows Alteration(s) ® Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [a] Other [o]
Brief Description of Proposed Ctc'►ta c.7
Work: 11JSvutT.t.J etTRoCK, 14SOFT /G001. *WIC ) Atab 1 WINboU) (RtAR).41•D •$ Srl+cvtt
bedroom Yes
S ��
Alteration of existing X No Adding new bedroom Yes X No SpoicE .
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll - Sheet
t o t [ rr-C c>'.I Inc rg s i'i q �c sa i� V hei 11rwi ii:
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 la'- OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS 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 work authorized by this building permit application.
Signature of Owner Date
C �
&)/ vl 5 • � C�IG�`� , as Owner /Authorized
Agent hereby 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.
6 IAN) C
Print Name
Signature of Owner /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 151 8`4' 1 s 1 t iii
Frontage i 101 i , O i
Setbacks Front p • j
Side L: L I i R:2 i CI L:i M. 1 R:` 1-` i
Rear
Building Height
Bldg. Square Footage 1 3 .0J i • ' % lAi 1 g i
,
Open Space Footage % i
(Lot area minus bldg & paved I3 K i I ? ]
parking)
# of Parking Spaces Y ° ° _,.
Fill:
(volume & Location) I j i
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO +,f DONT KNOW 0 YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES 0
r IF YES: enter Book Pag I and /or Document # °
B. Does the site contain a brook, body of water or wetlands? NO! DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q ,Date Issued
C. Do any signs exist on the property? YES 0 NO CS
IF YES, describe size, type and location: I mm
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO (F p
IF YES, describe size, type and location: I
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 (/14
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
s a ce s -
City of Northampton a � ' 2.�
Buildin Department - ° ° F i_' i t
212 Main Street d 4
Room 100 q ,
, -
DUI 1 3 LO10 o hampton, MA °41w3:5-87-127 1 6 y � a . _ �., ; `
d.. ,, : E.k3 :F ti
phony 413- 87 -124 Fax 2
S „ '
APPLI CATiON'f0 STRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
section to comp by o ffice
1.1 Property Address: ,
1.14 L16£2TY 5T Map Lot unit
F Lo «.£N G£, zone o District
Elm St. Dtstrlct CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
a� At4 S . i itAC�,� R. G�TtR� N f-. 14 L,i � �.T ST. �cb� o �o�L
Name (Print) g Address:
` �� _ . 41 Mailin —J17( CCU - /111674..5 r o.'t7 3�{ �
Telephone
Signature
2.2 Authorized Agent:
Name (Print) Current Mailing Address: This
Signature Telephone
CONSTRUCTION COSTS
Item Estimated C (Dollars) to be Official Use O eted nly
completed by permit applicant
1. Building Es (a) Building Permit Fee
11 , 0 00, 00
2. Electrical (b) tiotl Cast of
2.t°°° . d o Construc tio
n f (6)
3. Plumbing -- Building Permit Pee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1 +2 + +4 + 5) Z I, 0 Check Number /5 I�y '0� °
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings
Date
File # BP- 2010 -1158
APPLICANT /CONTACT PERSON GENCARELLE KATHERINE ELIZABETH C/O GIAN S CATERINE
ADDRESS/PHONE 44 LIBERTY ST FLORENCE
PROPERTY LOCATION 44 LIBERTY ST
MAP 30A PARCEL 054 001 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 /1/45',3( Xf' /V0
Tvpeof Construction: FINISH ATTIC FOR STORAGE SPACE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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
61z3110
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.
0
44 LIBERTY ST BP- 2010 -1158
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:B1oek: 30A -054 7, CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2010 -1158
Project # JS- 2010- 001693
Est. Cost: $21000.00
Fee: $126.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 15855.84 Owner: GENCARELLE KATHERINE ELIZABETH C/O GIAN S CATERINE
Zoning: URB(100)/ Applicant: GENCARELLE KATHERINE ELIZABETH C/O GIAN S
CATERINE
AT: 44 LIBERTY ST
Applicant Address: Phone: Insurance:
44 LIBERTY ST
FLORENCEMA01062 ISSUED ON: 6/23/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:FINISH ATTIC FOR STORAGE SPACE
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 6/23/2010 0:00:00 $126.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
0
Gian & Tracey Caterine
44 Liberty Street
Florence, MA 01062
JUN 242010
Hi Lou-
I wanted to be clear about our attic renovation project. There is basically no
structural change /framing to be done. The renovation consists of the following, in
the following order: a-i o c
1. Additional 110 electric service a nd 220 service at ground level to compressor
(see #5 below) 1■3. c d l 4 W A 1-A4 ( 11- 7
2. Rough cut opening for new window on south side of attic l
3. 4" foam insulation
(INSPECTION)
4. Replacement of collar ties (same size or larger than existing)
5. Installation of new window on south side of attic
6. Installation of Mitsubishi heating /cooling unit on south wall (compressor to
be located on ground under rear porch)
(INSPECTION- if necessary)
7. Sheetrock entire space
8. Cabinets built into eaves after sheetrock
9. Bookcases built on one side of existing chimney & on either side of new
window
10. Installation of railing on exposed sides of staircase opening
11. New Pergo floor on new 1 /4' sub flooring
I hope this helps clari , and thank you for your help.
Best,
Gian Caterine
617 - 510 -7734 (cell)