City of Peabody
Office of Inspectional Services
24 Lowell Street, Peabody MA 01960
Phone 978-538-5785 Fax 978-538-5987
HOMEOWNERS’ EXEMPTION ELIGIBILITY AFFIDAVIT
I, ________________________________________________________ (full legal name), born
__________________ (month, day, year), hereby depose and state the following:
1. I am seeking a building permit pursuant to the homeowners’ exemption to the permit requirements
of the Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a
project or work on a parcel of land to which I hold legal title.
2. I am not engaged in, and the project or work for which I am seeking the afore mentioned
homeowners’ exemption, does not involve the field erection of manufactured buildings constructed in
accordance with 780 CMR 110.R3.
3. I qualify under the State Building Code’s definition of “homeowner” as defined at 780 CMR
110.R5.1.2: Person(s) who owns 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 home owner.
4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I
qualify for and will abide by the Massachusetts State Building Code’s requirements for the supervision of
the project or work on my parcel, I am not engaged in construction supervision in connection with any
project or work involving construction, reconstruction, alteration, repair, removal or demolition
involving any activity regulated by any provision of the Massachusetts State Building Code.
5. If I engage any other person or persons for hire in connection with the aforementioned project or
work on my parcel, I acknowledge that I am required to and will act as the supervisor for said project or
work.
Signed under the pains and penalties of perjury on this _____ day of _______________, 20___.
_________________________________
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