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DEPARTMENT OF BUILDING INSPECTIONS r 4 �,i ■ i /-
INSPECTOR 212 Main Street • Municipal Building NNW '
O,y S`•
Northampton, MA 01060
e
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his /her construction supY:. isor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he /she resides or intends to be, a one or two fame y - --
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
.
o �iHAM p7, j
4, . . Crz�r of trz #l�ttnt � ►_ noi
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1 � DEPARTMENT OF BUILDING INSPECTIONS , Iwo a : / •
INSPECTOR 212 Main Street • Municip Building '
Northampton, MA 01060 °'M ,s•-
e
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his /her construction super•.'isor. 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
r
1
SECTION 8 - CONSTRUCTION SERVICES f
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Edwin Losacano CS SL 99739
License umber
128 Glendale Road - Southampton, MA 01073 l 1
Address Expiration Date
\ (413) 527 -0044
Signature Telephone
9 • Registered. = Home': lmprovemerittoiitractorilNEKZNIMVUAM , MM Not Applicable ❑
All Star Insulation & Siding Co., Inc. 10 I `i
Company Name Registration Number — _-
56 Franklin Street —
Address Expiration Date
Easthanpton, MA 01027 Telephone 413 - 527 -0044
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 ❑
11 Ha►me 0w.ner +me nation
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 - vear 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
r
SECTION 8 - CONSTRUCTION SERVICES /
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : EdWi n Losacano CS SL 99739
License umber
128 Glendale Road - Southampton, MA 01073
Address Expiration Date
(413) 527 -0044
Signature Telephone
• '+ R "'9 Y, lr.'Ye.53RR`�3'k2£;i�is 4 x,!,. .^Wj S:- xy Y. y f F4i '�5��
'9�Re sterecfifome_lmprovement. ontra - 616' �. " "` ` ri 4°"_ Not A licable ❑
All Star Insulation & Siding Co., Inc. 1 D \ ge >
Company Name Registration Number --
56 Franklin Street (D —
Address ( Z
Address Expiration Date
Easthampton, MA 01027 Telephone 413 - 527 -0044
SECTION 10= WORKERS' COMPENSATION INSURANCE AFFIDAVIT'(M.G.L. c. 15Z-§ 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 ❑
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 - vear 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, von 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
r
Section 4. ZONING All Informatihh 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 i
y
Lot Size - I —__ �_
1 — E f — ._�_�; S
Frontage --
Setbacks Front i j I 1
Side L: R:L L:i R _
Rear _
Building Height
i
Bldg. Square Footage I i ,
Open Space Footage %
(Lot area minus bldg & paved I I i I _ ! t
parking)
r— t S
# of Parking Spaces '
Fill: � — - - -- — —
(volume Bc Location) - -- — 1
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW Q YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW 0 YES Q
IF YES: enter Book Page and/or Document P; ! d / Dt #� —�
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW Q YES Q
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 Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q
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 Q r NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Section 4. ZONING All Informatibfl 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 I L _- _ 1
I II 1( i J
Frontage
Setbacks Front ' I I
Side L:I 1 R:` L:1 R.:! I 1
Rear =__I
Building Height --, - r — : 1_______.
—i --
1 4 f
Bldg. Square Footage I t I% ! I 1 i
Open Space Footage % I
(Lot area minus bldg & paved I l j_i i I L_
parking)
I r I i
# of Parking Spaces
Fill: ' j i
(volume& Location) — ___..1
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DON'T KNOW 0 YES 0
IF YES, date issued:1
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES Q
IF YES: enter Book j i Page; and /or Document #1
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q
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 Q
IF YES, describe size, type and location: I
•
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO 0
IF YES, describe size, type and location: i� _ 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 Q ,- NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•