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BP-59999RESIDENTIAL ❑ Approval in Part (Per 780 CMR.5111.13) $25.00 APPLICATION FEE IS NON RE -FUNDABLE & NON -TRANSFERABLE DATE RECEIVED r DARTMOUTH BUILDING DEPARTMENT ErT��Q : ?t 400 Slocum Road, P.O. Box 79399 t Y /A!5?� �SJmp 7�, Page 4 Page 1 RESIDENTIAL conn�ln� 21 Owner Record: ell —1/71 Name (print)— Contact Address Phone Number 2.2 Authorized gent: -2 Name (print) Contact Address Phone Number Mail 3.1 Licensed Construction Supervisor/Specialty License : License Number: Company Name/Contractor Name: v Address: - �,_ _ .. Expiration Date: Signature: Telephone:, 3.2 Registered Home Improvement Contractor. Not Applicable ❑� Are you a Home, Improvement Contractor subject to (780 CMR.110.R6)? ❑ Yes ❑ No Are you claming exemption from the requirements? ❑ Yes ❑ No If Yes, Go to Section 3.3 Company Name/Contractor Name: Registration Number (if none, state "none"): Address: Signature: 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 am a Homeowner performing all the work myself. r Owners Name (print): Signature: By signing the above, the ho ownef 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 5108.3.5 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individua 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 V 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 whic 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 s sig elow: 4l Signature: ur signature carries certain re onsibilities, including but not necessarily limited to, general liability rage z Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ Yes 0 No ..a:-A.:.S ..+i`,3s,✓/ -5r� .�,N', 1�.6ii3;. ..//9 ,�l - �, ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding 1i Other (Energy report required) (Shed/Garage) (Specify below) ❑ Addition ement window/door ❑Demolition (Energy report required) No.�placie ows 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 fiescription of proposed work: L4 Af 1A.1, T© �' ,r Estimated Cost ($) to be completed by permit applicant X/ Item 1. Building -0O0 0 ' 2. Electrical 3. Plumbing 3 4. Mechanical (HVAC) 5. Total = N + 2 + 3 + 4) C "7 C-5 a? (Please Print) (�` / ,� I - I, )ter-� 3 6✓ztb! as Owner of the subject property hereby authorize L/w,�, {� S�/ �'�c� U/, to act on my behalf, in all matters relative to work authorized by this building permit application. Sign of Owner Date I,Z1 on the foregoing.apl ✓AZ4 �rl as Owner/Authorized Agent hereby declare that the statements and information are true and accurate, to the best of my knowledge and belief. 9 ZO . Date Page 3