BP-15620RESIDENTIAL 2600
RESIDENTIAL 2000
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE
;nOUT"EGIylyED
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O. Box 79399
Dartmouth, MA 02747'
508-999-0720 FAX 508-999-0738
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH'A ONE OR TWO FAMILY DWELLING
Zoning Review: Signature:
Date:
Energy Report: Signature:
Date:
Fire Chief: Signature:
Date:
Board of Health: Signature:
Date:
Conservation Commission: Signature:
Date:
Other: Signature:
Date:
Description of work being performed:
NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes ❑ no
i
f 1.2 Assessors Plat & Lot Number:
.1 Property Address:
Plat-7 Lot -
Nearest Cross Street:
Subdivision Name: 13 Historical District ❑ yes Ano
Total Land Area Sq. Ft.:
01,36 Has application been submitted to the Historic Commission?
,
0 yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Private Well ❑ Municipal ❑ On Site Disposal System
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RESIDENTIAL
2000 RESIDENTIAL 2000
2.1 Owner of Record:
Name (print) Contact Address Phone Number
2.2 Authorized Agent:
ame (mint) _ Contact Address Phone gumber
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor
Address 17 0,0 0,AJ
Signature/�,�4,1 Telephoned
3.2 Registered Home Improvement Contractor:
Are you a Home Improvement Contractor subject to (780 CMR-6)? t<yes ❑ no
If no, go ksu
he next section!
Are you claiming exemption from the requirement? ❑ yeso
If yes, mit the
required affidavit!
Company Name
Address ,,,.-) f
Not Applicable ❑
License Number , L
Expiration Date
IOZ—
Not Applicable ❑ llO/Y.
07F
&i1;,eAsce
Registration Number (if none, state "none")
Signature Telephone �, Expiration Date --��' �---61
3.3 Fc-r 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, :LIA 02108, (617) 727-8598
Owners Name (print)
Signature
Date by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
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
shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of
buildings or structures, unless he or she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing
Construction Supervisors.
Exception: 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 dwelline, 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: `
S ignature:
r our slgnautre carries certain responsibilities, including but not necessarily limited to, general liability
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