BP-36604RESIDENTIAL
2004 RESIDENTIAL 2004
❑ FOUNDATION' ONLY
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE $25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE
P ��a°TH•�;;� DARTMOUTH BUILDING DEPARTMENT m,
DAAI kE1VED
1. Date plan reviewed:
2. 30 days to review period expires:
0� 400 Slocum Road, P.O. Box 79399
.z ,�,a
Dartmouth, MA 02747
�,:, ;
3. OK to issue date:
508-910-1820 FAX 508-910-1838
4. OK to issue subject to requested submittals (see project review worksheet):
Date:
5. DENIED (see project review worksheet):
Date:
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
6. HOLD reason:
Date:
7. HOLD subject to Zoning Board of Appeals action:
Date:
8. Comments:
Date: <
9. Inspector's Signature:
Clerk:
Applicant informed of above Date: Time:
Comments:
Remaining Balance: $
Total Permit Fee: Less Application Fee: $ 25.00
TOTAL FEE: C/'�, Gross Area- New Construction total sq. ft.
< Gross Area - Alteration total s f ,
Zoning Review: Signature: Date:
Permit Issued To:
Energy Report: Signature: Dater
Chief: Signature: Date:
Board of Health: Signature: Dater
Conservation Commission: Signature: Date:
Other: Signature: Date:
Description of work being performed: n CD;C L 7ic- .A £r-
ElmFire
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NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes ❑ no
1.2 Assessors Plat & Lot Number:
' 1.1 Property Address: Lir tc.t2, Plat ---(—Lot -
Nearest Cross Street: *'2M4 iA CA- (T,l;� .
Subdivision Name: MI-S4d W&A 1'1.3 Historical District ❑ yes ❑ no
Total Land Area Sq. Ft.: 4Z., ff Has application been submitted to the Historic Commission?
❑ yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System:
❑ Municipal *KPrivate Well ❑ Municipal ❑ On Site Disposal System
Rev. January 1, 2003 C:\bldg.forms\Bldgapp.res.wpd Page 1 Rev. January 1, 2003
C:\bldg.forms\Bldgapp.res.wpd Page 4
RESIDENTIAL
11
2004
2.1 Owner of Record: #e#9A- d
Name (print) Contact Address Phone Number
2.2 Authorized Agent:
Name (print) Contact Address Z,''lLf Phone Number
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor License Number
Address Expiration Date
Signature Telephone
3.2 Registered 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❑)
ISignature Telephone I 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
Owners Name (print)
Signature
by signing the above, the home owner acknowledges that there will be no eligibilty 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
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 oriVhich 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:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
C:\bldg.forms\Bldgapp.res.wpd Page 2 Rev. January 1, 2003
C:\bldg.forms\Bldgapp.res.wpd Page 3 Rev, January 1, 2003
: H/GAFDM/03-5990/
\, MAP 7
\ LOT 17
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SYMBOL DESC.
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3. LOCUS IS SHOWN AS LOTS 15 & 16 ON ASSESSORS MAP 7.
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