BP-62661RESIDENTIAL ❑ Approval in Part (Per 780 CMR.5111.13)
$25.00 APPLICATION FEE IS NON HE-FUNDARLE
D` `:' ' CEIVED
4.�Ji.. ih7
DARTMOUTH BUILDING DEPART ME
400 Slocum Road, P.O. Box 79399t d
3 Dartmouth, MA 02747
,�6A; . 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
Zoning Review: Signature: Date: MAR 2 3 201
Energy Report: Signature: Date:
Fire Signature: Dater
!!�oa:rd�of.-Signature: Date:
Conservation Commission: Signature: Date:
Other: Signature: Date:
Brief description of work being performed:,— f?f'ff!l.
Property Address: P V a 1.2 Assessors Map & Lot Number:
Lot Area (sf.) Frontage Map ` Lot
Required Provided
Front Yard 1.3 Historical District ❑ Yes ❑ No
Side Yard
Rear Yard
Year Built
❑ Altering more than 25% per side of building
.4 Water Supply (MGL c40 s54): JXISSewage Disposal System: Has application been submitted to the Historic Commission?
❑ Municipal [(Private Well ❑ Municipal �'On Site Disposal System ❑ Yes ❑ No Date:
CONSTRUCTION PLANS SITE PLAN 0 ENERGY REPORT
Page 1
RESIDENTIAL
1 Owner Record:
/V (A/ a -S
Name (print) Contact rass Phone Number
C .l
073
2.2 Authorized Agent:RAecr r113
-
Name (print) Contact Address Phone Number
.,,.. , ..'_�.RSEC. 110W Ai` a -4�i2�'it'�}`i��8.`
'j 3.1 Licensed Construction Supervisor/Specialty License . License Number. l8 C-
Company Name/Contractor Name:
C Address /" !; ��j�,py� p Expiration Date:
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® fdl
Signature: Telephone:5-1* r — G f
P 3.2 Registered Home improvement Contractor. Not Applicable ❑
j(
E Are you a Home Improvement Contractor subject to (780 CMR.110.R6)? ❑ Yes ❑ No ' ;o
Are you claming exertion1rom4he r u r ments? ❑ Yes ❑ No
I _ If Yes, Go to Section 3.3
Company Name/Contra for Name Registration Number (if none, state "none"):
Ck . y r�
Address: /
E Signature: Telephone S � ej Expiration Date: ello
N 3.3 For Residential Remodel Work Only
C PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
EQUESTIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration, One Ashburton P
�S� 9 � lace Room 1301, Boston, MA 02108, 617-727-8598
❑ i 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 tyto 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
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
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1tyi3REl S ,t16�tPSs°4T)NkINSIi(YACE AFrIbAVIT (fi(�L�c i2��5��,f
Worker's Compensation Insurance Affidavit
p davit 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
r
���.r,❑k
!MIXi't2'
❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ AccessoryBldg. g Roof in /d9 ❑Other
(Energy report required) (Shed/Gars e) (Specify below)
❑ Addition XReplacement 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):
❑ 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
Description of propose work:
e
Item
pleted by permit applicant
7.77T
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
kz
5. Total =(1+2.+3+4)
(Please P nt)
I,� �� Y �A i C;+ �� s Owner of a subject property hereby authorize —Lb F-rqli Sc�
L� L
to act on my behalf, in all tters relative to work authorize by this building permit application. V
natu of Ow Date
p
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S �� as Owner/ th rize A � d gent h eby declare that the statements and information
on the foregoing application are f e and accurate, to the best of my n ge and belief.
Signed under the pains and penalties of perjury.
Signature of Owner/Authoriz d Agent
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