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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 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 ins , ection if re uired and a final buildin ins ' ection. 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- inoonjunctionto_thebuilding Termitissued,_ 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.
Address of work
location
The Commonwealth of Massachusetts
Department of Industrial Accidents t � / i=-,
_ i ce ,, Office of Investzgations 1 /
moons ' 1� 600 Washington Street
if
?" r ay
�� Boston, MA 02111
'sue www.mass.gov /dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LegibIv
Name ( Business /Organization/Individual): / /ryt- , ,J IikJ j 'n . (.O1/112.4 _
Address: Po, /
City /State/Zip: C# Wm- G /e// A. 4/U /2- Phone. #: 1 7/ 3 - 297 - . 5 - 7e y
Are u an employer? Check the appropriate box: Type of project (required): 1
1.I am a employ er with 4.. ❑ I am a general contractor and I
6. ❑ w construction
employees (full and/or part- time).* have hired the sub- contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet 7. Remodelin
ship and have. no. pplo Tees These sub - contractors have. 8. ❑ Demo;ition
working for mein an capacity. employees and have workers'
Y p ty. 9. lrli addition
[No workers' comp: insurance comps 1 ns u ra ❑ Btu
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3. ❑ I -am --a omeo ner-doing all - work o liaye Y,ezaised heir — 1-1.❑ - Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13. ❑ Other
comp. insurance required}
*Any applicant that checks box #1 m also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this afftdavit .indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check 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 - contractors have employees, they must provide their workers' comp. policy number.
•
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information
Insurance Company Name: // Li, ad/c,0 6 „h f.
Policy # or Self-ins. Lic. #: IV C 2 - 3 /S - ..?if Z. /41 - 0/1 . Expiration Date: ie,04 9..6 , .2O/0
Job Site Address: .fi 4w , ion I A City/State/Zip:' -
�� �P /Z � � �i . / 1 9,/d i
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section - 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fne up to $1,500.00 and/or one :year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator: lie advised that a copy of this statement may forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the , ains and penalties ofp. erjury that the information provided_ above_is_truemudcorrecl - _
_
S i . : D ate : - (
Phone #: / - '7- /cSG
- O ff i c i a l u s e o n l y . Do n o t ` w a l e in this area; to be completed by city or town
City or Town: Permit/License #
Issuing Authority (circle o
-1. Board of Health 2. Buildi ng Depa:rtmen- 3. City/Town Clerk 4. Eiectrical_inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #: -