43-081 4
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City of Northampton `
-;-.4f4,4" `° Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
\ Northampton, MA 01060 PSG ti4C
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
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 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 home owner."
The building department for the City of Northampton wants any 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 permits 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
understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date
Address of work location
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City of Northampton _
J q. Massachusetts 4,, ,
1 *4 $ y «, � $ j DEPARTMENT OF BUILDING INSPECTIONS ..- � `
' t „ .4 212 Main Street • Municipal Building '''''):;.\ , 0.$'.
ti Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
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 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 home owner."
The building department for the City of Northampton wants any 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 permits 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, understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date
Address of work location
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : �({ C Ci Ur? 6. Let :�„J s 3 3n % C_ S 7 2 Z.
License Number
i S Cam;L, ti •- C2- ... , , -rti e _ , '- 2 - - �a i'r3
Address g itk A, Expiration Date
tfl3 7— - 2-7 / C, -------) Sign e Tel �e
9 a: eiiistered ome.Improvement >Contractor , v7 x _ll , a, . ; '°�-�- „ C° Not Applicable ❑
Company Name // l Registration Number
(_�L.�A- � r X S --771 117?!°U,'e1 -/ - 2- - f 3
Address Expiration Date
Telephone V4,3 2-9 7-2-6g,
,
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 IC No ❑
. ..: Home. . O -Exe
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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
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SECTION 8 - CONSTRUCTION SERVICES F
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : (-{ G [S? ly. le .J uQ i G ` ' '2 2 2.
License Number
('? - g L Nom- (2 I CT. —T 8' 13
Address ire/■ p Expiration Date
(.03 2 - 7 - y`I 16,
Sign a Tel ne
=ee eredµ " ome- m . rove en ontrictor..' ;..- " t, , . * ,4 ,; t f. Not Applicable ❑
�� t �z - c,.J / 3 2. 751
Company Name Registration Number
L._ A—, ek1 fir ". `1. -13
Address Expiration Date
Telephone V/3 2-?
SECTION 10- WORKERS' COMPENSATION INSURANCE (M G L c152, § 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 lY_ No ❑
11 nle�Owner cemptio
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
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S.'
l' i i Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Inc mplete Information f
Existing Proposed Requi d by'Z'oning `T
This colum`iTte.be filled in by f
Building Department
Lot Size m ' ' f
Frontage
Setbacks Front f [ 1
Side L:` R:' L: R: :
I I ?
Rear
Building Height
Bldg. Square Footage r 1 % 1
Open Space Footage % ,—
(Lot area minus bldg & paved I 1 I ; -i
parking)
1
# of Parking Spaces
Fill: j
(volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES Q
IF YES: enter Book i Page; i and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW Q YES i
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
IF YES, describe size, type and location:
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 Q NO :1,�4
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Inc plete Information g
e • ,. s
. /
Existing Proposed Requi d by'Loning
This colnmfireft.be filled in by
Building Department _ r
r
Lot Size
1 i1 11 #
I j 1 1
Frontage ■
Setbacks Front r , 1 E
I-- r
Side L:! I R: L:LJ R:I
Rear ! 1 1 1
Building Height ! ! 1 I
Bldg. Square Footage 1 1 1 1% 1 1
Open Space Footage _ %
(Lot area minus bldg & paved z 1 1 1 i
parking) ,
# of Parking Spaces 1 1
Fill: _ _ _ _ �_ ______
(volume & Location) : i
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
I .
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
I NO 0 DONT KNOW 0 YES Q
IF YES: enter Book i i Page! I and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location: 1
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO
IF YES, describe size, type and location: 1
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 Q NO i0•4
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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