23A-170 City of Northampton
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, DEPARTMENT OF BUILDING INSPECTIONS r r
212 Main Street • Municipal Building �y�. a)
`'�, : � , Northampton, MA 01060 "P �
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 ins ections are made
I, / f ' � e /� t h 40 (2 l} .i� k- 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 (' o .i--- Cc- °Lc) i '
Address of work location
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City of Northampton ,
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, Massachusetts _�, S t y
SDI a of
"�� DEPARTMENT OF BUILDING INSPECTIONS it
212 Main Street • Municipal Building t ai - �
V "�„ ' " "" Northampton, MA 01060 ' y`
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
lie /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 in ections are made
1,
T A j o / 6 1-10q. h i understand the above.
(Homener /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date M 1 (c `2.0 1
Address of work location
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SECTION 8 - CONSTRUCTION SERVICES
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8.1 Licensed Construction Supervisor: Not Applic ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
egisteredome 'gym' "''viovemenContira "ctar ',. : n, 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 ❑
1i l om Ow ier xemj tion
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 Buildjng Official, on a form acceptable to the Building Official, that he /she shall be
res • onsible for all such work • erformed nder the buildin ! • ermit.
As acting Construction Supervisor your • esence on the job site will be required from time to time, during and upon
completion of the work for whi this pe •it is issued.
Also be advised that with refere ce to Cha; ter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resul ing in De. ) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for yo under t permit.
The undersigned "homeowner" tcertifies . ass mes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, Stat , and •' . • onip Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature I x
•
SECTION 8`- CONSTRUCTION SERVICES , `J
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
e • iiter.e&:' omex ni • rovemen *; ontractar ` . V" 1 -; .�' 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 ❑
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
res onsible for all such work . erformed nder the buildin I ermit.
As acting Construction Supervisor your . esence on the job site will be required from time to time, during and upon
completion of the work for whi this pe I. t is issued.
Also be advised that with refere ce to Cha l ter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resul ing in De. ) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for yo under t • permit.
The undersigned "homeowner" certifies . ass mes responsibility for compliance with the State Building Code, City of
- - Northampton Ordinances, Stat end •' • oni ; Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
•
.,
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by oning
This column to •e fillld in by
Building Dep:tuienV ;
e
Lot Size f .5t
,
Frontage 7,5 4
Setbacks Front =I j J Z'
Side L: €/' R: L:4 P i R: ? 1
Rear
Building Height I 'L S' v •
Bldg. Square Footage 3 oz. W ,
Open Space Footage % f 1 4 {
(Lot area minus bldg & paved J R3 11 , '-'
C
pazkmg) 7
Z `
# of Parking Spaces
Fill: i.
(volume & Location )
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES
IF YES, date issued:. /0 2—T q 5 i
IF YES: Was the permit recorded at the Regist of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Page; ? and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO ®DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location: i
D. Are there any proposed changes to or additions of signs intended for the property ? YES l NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, exca on, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
a
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplet,'lnformation
Existing Proposed Required by' oning ,
This column t. .e fillld in by
Building Dep- ...enl*, -, G
„,
Lot Size E yl.— i 6 • I „ "
Frontage
i 75 !I "qS `
Setbacks Front I y V>
Side L:' R:= L: R:I I
Rear
Building Height a.-.2r .0 rEslry- iv
Bldg. Square Footage .-NA I % rAmg 1 i
Open Space Footage
(Lot area minus bldg & paved l) 1_____J L'E C
parking)
# of Parking Spaces
Fill: I 1 W
(volume & Location)
i
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES J
IF YES, date issued:} /O , q V f
IF YES: Was the permit recorded at the Regist of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book I Page; j and /or Document # i t
i
B. Does the site contain a brook, body of water or wetlands? NO ®DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued:
3
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 0 NO
IF YES, describe size, type and location I
E. Will the construction activity disturb (clearing, grading, exca on, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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