BP-600121. Date plan reviewed: ' lUN 0 Z—2010
2. DENIED (see project review worksheet):
Date:
3. HOLD
Reason:
Date:
4. HOLD subject to Zoning Board of Appeals action:
Date:
Comments:
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Inspector's Signature:
Dater JUN
0 2 2010
Applicant informed of above: Date: Time:
Clerk:
Comments:
_,,
Total Permit Fee; $ �,�
Less Application Fee: $25.00
Remaining Balance:
$
Other $ Amount $
TOTAL FEE: 7 ') Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
01
RESIDENTIAL ❑ Approval in Part (Per 780 CMR.5111,13)
$25.00 APPLICATION FEE IS NON ME -FUNDABLE & NON-TBE
DARTMOUTH BUILDING DEPARTMENT
nl
400 Slocum Road, P.O. Box 793990.9' 26
Dartmouth, MA 02747
Phone: 508-910-1820 Fax: 508-910-1838
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
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1.1 Property Address: 16 3 e51'1� c c wl I • �Cx 1.2 Assessors Map & Lot Number:
Lot Area (sf.) Frontage Map __T_ Lot
-
Required Provided
Front Yard 1.3 Historical District ❑ Yes 1No
Side Yard Year Built
Rear Yard
❑ Altering more than 25% per side of building
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Dis 'osal System: Has application been submitted to the Historic Commission?
❑ Municipal Private Well ❑ Municipal 70n Site Disposal System ❑ Yes ®.}}No Date:
Page 4 ❑ CONSTRUCTION PLANS 1-1SITE PLAN 0 ENERGY REPORT
Page 1
RESIDENTIAL
2.1 Owner Record:
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Jya w'l - J e,(�e icJ-,P.rd
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Name (print)
Qoptact Addrg ss Phone Number
[VP w 7,6f v C r��7 r
2.2 Authorized Agent:.
4 v�S�'ec � � s G��.�'T7
Name (print)
Contact Address e Number
4'0-� 7� r
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3.1 Licensed Construction Supervisor/Specialty License: License Number: C (Z p r
e.
Company Name/Contractor Name: v ipggC tI�, � p Sl� Prd ,�rQP try."
Address: tow
Expiration Date:/ -
�2'j i �0 1(
/
Signature: Telephond � t �'f�t ® 12
3.2 Registered Home Improvement Contractor.
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMRA 10.R6)? des ❑ No
Are you claming exemption from the requirements? ❑ Yes 2/No
If Yes, Go to Section 3.3
Company Name/Contractor Name:
Registration Number (if none, state "none"). -
Address: 'Fbcct k Pt"pC��, m2j,6
Signature: Y Telephon . f+d ( _ 7 (
Expiration Date: �, N I20 (1
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.
Owners 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
6108.3.5 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individus
shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of building.
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 Constructioi
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 Homeowne
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 whit
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 the
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
rays 4
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide thh'Lo
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ Yes �7 No
010T,'z . . . . . . . . . . . . . P
❑ Deck ❑ Pool ❑ Repairs ❑ 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):
0 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 zl Fuel Oil Other
Description of proposed work:
a 3 m n, -
n,
Item Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = (1 + 2 + 3 + 4)
(Please Print)
1, as Owner of the subject property hereby authorize
to act on my behalf, in all matters relative to work authorized b this building permit application.
Signature of Owner Date
rage 3