BP-47319❑ SPECIAL PERMIT (Per 780 CMR 111.13)
1. Date plan reviewed:
2. DENIED (see project review worksheet):
3. HOLD
Reason:
4. HOLD subject to Zoning Board of Appeals action:
Comments:
Date:
Date:
Date:
V \1-IV
Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: $ d
Other $ Amount $
TOTAL FEE: goo, Co Gross Area - New Construction total sq. ft. SG FT
Gross Area - Alteration total sq, ft.
Permit Issued to: A012 o „p c I' S 7- Fe Ll�,� t,/s o z.,l / C So let- A/o t/'/ Two �
r
r SQ /"T X. 7 - Aso a(3
/« A10
�)(/3= 390,
( Y / d 60
Y`-5r - o Asa a 0
$23.00 AYPLIUNfION FEE IS NON RE -FUNDABLE UNDABLE & NON -TRANSFERABLE
�Nou N •.� DATE 1 CEIVED
_ . .,
P1, DARTMOUTH.BUILDING DEPARTMENT
'� 400 Slocum Road, P.O. Box 79399. p) $j
Dartmouth, MA 02747
Lit
1664 Phone: 508-910-1820 Fax: 508-910-1838
www.town.dartmouth.ma.us
APPLICATIOitTOAONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Zoning Review: Signature: Date: G S d C
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: Lk Date:
Other: Signature: Date:
Brief description of work being performed:
1.1 Property Address: _1 /-�
Nearest Cross Street:
Subdivision Name: 7 q
Total Land Area Sq. Feet:
1.4 Water Supply (MGL c40 s54):
❑ Municipal ❑ Private Well
1.2 Assessors Map & Lot Number: /
Map Lot L -
1.3 Historical District ❑ Yes No
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Dater
1.5 Sewage Disposal SyT
❑ Municipal Site Disposal System
❑ CONSTRUCTION PLANS ❑SITE PLAN ❑ENERGY REPORT
RESIDENTIAL
;SECTION 2 - PROPERTY'OWNI~RSHIP/AUTHORIZED
AGENT
2.1 Owner Record:
VA �2 P)p4—Z�-. �` _ 'S3c�v c��p 5
� �►t C�v V.A-� 1`. �t'_ 1J`i
Name (print)
Contact Address Phone umber
2.2 Authorizggd Age t:
d1 AN� oys
Name (print)
Contact Address Pl�oneJ,Vu-b ier
�a • �4 o
SECTION 3 -CONSTRUCTION SERVICES •:
3.1 Licensed Construction Supervisor.
Not Applicable
` \
Licensed Construction Supervisor: 2JAZ
License Number. 157 3 ,5,
Address:
Expiration Date: to
Signat Telephone: • �=6 b
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? I Yes ❑ No
If No, go to the next section!
Are you claming exemption from the requirements? ❑ Yes II21"No
If Yes, submit the required affidavit!
tt
Company Name: t OlS CtJ %trr)� N
Registration Number (if none, state "none"):
68
Address'
Signat Telephone:
Expiration Date:
3.3 For Residential Remodel Work Only
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, 617-727-8598
❑ 1 am a Homeowner performing all the work myself.
Ownere-: Name (print):
Signature:
By signing the above, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund
Date:
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR'OWN PROJECT
109.1.1 Licensing of construction Supervisors: Except for those structures governed by Construction Control in Section 116.0,'effective July 1, 1982, no individual
ail 1 be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of buildings
a1. 'ructures, unless he or she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing Construction
irvisors.
option: Any Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section; provides that if a Homeowner
engages a person(s) for hire to do such work, that such Homeowner shall act as supervisor.
For the purposes of this section only, a "Homeowner" is defined as follows: 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 Homeowner.
If you are applying under this section sign below:
Signature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Requlations section that anv licensed Constnicti
bupervlsor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15)
y ;SECTION , ,:WORKER'S;COMPENSATION�INS.URANCE AFFIDAVIT (MGL c 152 §25) s
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure torovide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: H es ❑ No
❑Deck ❑ Pool ❑ Repairs I Alteration ❑ Chimney/Fireplace
❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding
❑ Other
(Energy report required) (Shed/Garage)
(Specify below)
❑ Addition ❑ Replacement window/door
❑ Demolition
(Energy report required) No. of windows _ Doors _
(Specify below)
*If new construction, please complete the following:
Single Family: No. of Bedrooms No. of Baths
Two Family: No of Bedrooms Unit 1 No. of Baths Unit 1
No of Bedrooms Unit 2 No. of Baths Unit 2
❑ Furnace (hot air) - fuel gas (natural or, propane), fuel oil, electricity, other (specify):
❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Descriptipp of proposed work:
r_c L. C
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
ao G
2. Electrical
�v
3. Plumbing
4. Mechanical (HVAC)
5. Total = (1 + 2 + 3 + 4) 1
'71" �..,.�
(Please Print), \ '
I, �' - �✓`— �` --- as Owner of the subject property hereby authorize 4t-A
to act on my beha , in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, T�,� J jc) � as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
t 2 111610X
Date
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