BP-36895RESIDENTIAL
2004
❑ FOUNDATION ONLY
$Zv.UU APPLAUATIUM JrLK iS MUM
A NUN-WJKAN5Y&1KAJS1mE
1. Date plan reviewed: %1 / %
2. 30 days to review period expires:
3. OK to issue date:
4. OK to issue subject to requested submittals (see project review worksheet): Date:
5. DENIED (see project review worksheet): Date:
6. HOLD reason: Date:
7. HOLD subject to Zoning Board of Appeals action: Date:
8. Comments:
9. Inspector's
Applicant i
Comments:
of
Time: ell -1
Date:
Total Permit Fee: $ LDL/ Less Application Fee: $ 25.00 Remaining Balance: $ .
TOTAL FEE: . Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued To: _
ea i
RESIDENTIAL 2004
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE dt NpN-TRANSFERABLE
o�T,,. 9` tt.;"n�k ACEIVED
DARTMOUTH BUILDING DEPARTMENT
o 400 Slocum Road P.O. Box 79399 4 1 011 - . P. =,a
II: 51
Dartmouth, MA 02747
r
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Zoning Review: Signature: DEC 17 2 0 Kte:
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
y
Board of Health: Signature: Date: �` 2-3r0c1
Conservation Commission: Signature: Date:
Other: Signature: '� A Date:
Description of work being performed: A-,-- ��2 W�t��1�" �qtay— 12f-
NUMBER OF PLANS SUBMITTED:
1.1 Property Address: Z PC, or 0'>�
Nearest Cross Street: %& t T-4
Subdivision Name:
Total Land Area Sq. Ft.: lO , 6:5 �
1.4 Water Supply (MGL c 40 § 54):
❑ Municipal
SITE PLAN SUBMITTED: ❑ yes ❑ no
1.2 Assessors Plat & Lot Number:
Plat_ Lot t (.::I -
1.3 Historical District ❑ yes Flo
Has application been submitted to the Historic Commission?
❑ yes ❑ no Date:
1.5 Sewage Disposal System:
vate Well ❑ Municipal XOn Site Disposal System
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Pagel
Rev. January 1, 2003
RESIDENTIAL
2.1 Owner of Record:
Name (print)
2.2 Authorized Agent:
Name (print)
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor
Address 6�
Signature
3.2 Registered Home Improvement Contractor:
2004
MR--. ®z. ,�i f
Contact Address L C Phone Number
Contact Address Phone Number
Are you a Home Improvement Contractor subject to (780 CMR-6)? _;Kyes ❑ no
If no, go to the next section!
Are you claiming exemption from the requirement? -0 yes X* a 0
If yes, submit the
required affidavit!
Company Name x2t',bt l 4)ryS� i L.
Address o IV &t , Z 013,2,0
Signature Te ephone7 ® o
3.3 For Residential Remodel Work Only
Not Applicable ❑
License Number 6&
Expiration Date
-&/Z,Z, / (9 g—
Not Applicable ❑
Registration Number (if none, state ❑ none[])
Expiration Date
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 on which 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
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