BP-23464R F'.CTTIF.NTT A T ,
2002
2002
SECTION 8 - INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed: /3 —J1^00-
2. 30 days to review period expires:
3. OK to issue date:
4. OK to issue subject to requested submittals(see project review worksheet):
5. DENIED (see project review worksheet):
6. HOLD reason:
Date:
Date:
Date:
7. HOLD subject to Zon' g B _61f eal
Date:
S. Com nts:
9. Inspector's Signature:
Date: 1
S CT N 9- APPLICAN N TIFICATION
q
Appli ant informed of bove Date L Time:
mments: y' o
Clerk-
SECTION 10- OFFICE\INSPECTOR'S NOTES
Total Permit Fee: $
Less Application Fee: $ 25.00
Remaining Balance: S 'e.
1
TOTAL FEE: gip, 9 0 Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
®)<
Permit Issued To•
SECTION 11 - ADDITIONAL COMMENTS/SKETCHES
-�
P
RESIDENTIAL ❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE
DAIIC)lIV11D
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O. Box 79399
v1' }
Dartmouth, MA 02747'`
-
03
«:°...>' 508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY:
BUILDING PERMIT
DATE SENT FOR REV E 3--19-04
NUMBER:2 3 �&.y
-
DATE ISSUED•
OK TO ISSUE - SIGNATURE: DATE
Building Co issioner/Insp or of Bui i s
Zoning; District:••>1 Proposed Use: Zone: a ❑ B ❑. V Outside Flood Zone ❑ Aquifer Zon
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑ Board of ❑ Board of ❑Con. Com. ❑ Demo ❑ DPW ❑ Elec. ❑ Energy Report
Appeals Health Affidavit Card Sent: Cut Off Follow-up*
❑ Fire ❑ Gas ❑ Planning Board*, ' ❑ Sewer Card ❑ Water Card ❑ Zoning ❑ Other
Chief Cut Off / Cut Off / Cut Off Review*
* REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPAR91SNTAL APPROVAL
Zoning Review: Signature: yw Date:
n b Signature: Date:
Fire Chief: Signature: Date:
'�'�' �� ` 3 -'LO CZ,
Board of Health: Signature
1_Date-
ri i� A
Conservation Commission: Signature: Date:
Other: Signature: N'" Date:
Description of work being performed: `` l� . r ► '� -�
SECTION 1- SITE INFORMATION
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes ❑ no
1.2 Assessors Plat & Lot Number:
1.1 Property Address: 169 h1 h,,.,^ �,k&
Plat Lot -
Nearest Cross Street: b.,n °`A 1y e'k ko .
1.3 Historical District ❑ yes Xno
Subdivision Name:
Has application been submitted to the pistoric Commission?
Total Land Area Sq. Ft.:
❑ Date:
yes W"no
1.4 Water Supply (MGL c 40 § 54):
1.5 Sewage Disposal System:
❑ Municipalwprivate Well
❑ Municipal )I�On Site Disposal System
C:\bldg.forms\Bldgapp.res.wpd Page 4 Rev. January 19, 2001
C:Abldg.for 1SyBtd��app.res.wpd
Page 1
Rev. January 19, 2001
RESIDENTIAL
2002
RESIDENTIAL
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 of Recar
&���,�z y^
iOwner
I r
F V,aoy► "De 0 � 1 � 12: (5 IV
i (69 M is6gm &+ R tD CrO'6)1161`1
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
&VIlf'A &23kc- Roh4- Sra 44-tXne
1? OC-en.i Ave. C3�s) any-Sfte�"�
Name (print)
Contact Address Phone Number
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor v
License Number 0-7 Vio
Address `7 kJ , n
Expiration Date
l I ��.o�q
Signature Telephone C vsy�g�,g
3.2 Registere(Home Improvement Contractor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ yes )<'no
If no, go to the next section!
Are you claiming exemption from the requirement? ❑ yes ❑ no
If yes, submit the
required affidavit!
Company 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:
Hoare Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, (617) 727-8598
Owners Name�prmt)
Signature _
/- � fo — by signing t eabove, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
Date l I
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:
Signature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
2002
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15)
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL C 152 § 25)
Workers 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 ❑ no
SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable) '
❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ ❑ woodstove
(energy report required) (energy report required) fireplace
❑ deck ❑ pool k accessory bldg. ❑ replacement window/door ❑ other ❑ demolition
(shed/garage) no. of windows doors (specify below): (specify below):
* If new construction, please complete the following: i
Single Family: no. of bedrooms no. of baths
Two Familv: no. of bedrooms unit 1 no. of baths unit I
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 (specify):
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Brief Description of Proposed Work: r t
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbin
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4)
* Estimated Total
SECTION 7A - OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)'
(Pleas print)
I> , as Owner of the subject property hereby authorize l !rY! l
to act n in a f, in 64 matters relative to work authorized by this building permit application.
`aIt
Signature of Owner Date
SECTION 7B - OWNER/AUTHORIZED AGENT DECLARATIO
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.
Signed under e pains and penalties of perjury.
Sign re of Owner/Authorized Agent Date
C:\bldg. forms\Bldeapp.res. Nvpd
Page 2 Rev. January 19, 2001 C:\bldg.forms\Bldgapp.res.wpd Page 3 Rev. January 19, 2001
Foy o 9
m F C � 11@d ;lAmp
A APPR 3 C A. A 12 c y ,H �FMgss TITLE: PROPOSED GARAGE SITE PLAN
NzaA p c� N o ���° 9°y:. OF
o m \ � z A o �+ N, HNEIDE S (• 169 MISHA UM POINT ROAD
A ., 1.� o SCHNEID m
N p q or�o a n F~.r. 9 CIVIL ER -+i
Na 38540 SOUTH DA R TMOU Tf7j MA
vi .e A o o a
y ®►�oN PREPARED FOR: FRANCES D. PINGEON
m r SCALE: 1 "=30' DATE: MARCH 7, 2002
o a y *1 0 30 60`' 90
N. DOUGLAS SCHNEIDER & ASSOCIATES, 'INC.
PROFESSIONAL CIVIL ENGINEERS
c a 1 COUNTY RD, P.O. BOX 480, MATTAPOISETT, MA 02739
e o p 1-508-758-7866
DRWN BY: GCH CHK BY: NDS SHEET#: 1 OF 1 JOB#: 964
1
i
L
I 4 0' WA Y
I
I
IS 85:48- 0" E S 85*58' 20" E
I 37.29'
124.47'
I
I I 3
MAP 7 o
l o I LOT ll "0�
j
I Q
I � i
I
o-1611 —,I\LS
I
u._.._... ! S 85022' 00" E 104.00' _...._.. .._.
Qcl
7
q I z I ���
I N
l I v N
q !�
0 119.8'
I OT' TAG
�
325' +1-
I
I � I
I I
I I
I
�`
Q� 172.59' 290.2T +/- COPPER PLUG /N ROCK(FND)
N 85058' 20" W N 86'34' 20` W
MAP 7 LOT 19
MAP 7 LOT 13
APPROVE TITLE: PROPOSED GARAGE SITE PLAN
=� 0oFMASS gcyG 769 MISHA UM POINT ROAD
DOUGLAS SOUTH DA R TMOU Th; MA
a SGIINEIC CIVIL N
U
No. 38540
o
rsTE�. PREPARED FOR: FRANCES D. PINGEON
FsSroN ,
'►► SCALE: 1 =30' DATE: MARCH 7, 2002
i 3 0 30 60 90
N. DOUGLAS SCHNEIDER & ASSOCIATES, INC.
PROFESSIONAL CIVIL ENGINEERS
1 COUNTY RD, P.O. BOX 480, MATTAPOISETT, MA 02739
1-508-758-7866
hRWN BY: GCH CHK BY: NDS SHEET#: 1 OF 1 1 JOB#: 964