BP-13541SIDENTIAL 1999
SiCiTO1V:$ INPEC iQR'S REVIElVIC011tENT
I. Date plan reviewed:
2. 30 days to review period expires:
3. OK to issue date:
4. OK to issue subject to requested submitta(s(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 Signature:
Applicant inform d.,olfab
Comments:!1
ECTI ?N � A PLICA T :\'4TJFIC:1TION
Date:- -/ ' / ' Gf Time: 0 ` 55 Cleric:
Total Permit Fee: S Less Application Fee: $ 25.00 Remaining Balance: $ T
TOTAL FEE: / �� Gross Area - New Construction total sq. ft. /f 3
Gross Area - Alteration total sq.. ft.
Permit Issued To- f
Y
RESIDENTIAL ❑ FOUNDATION ONLY 199�
$25.00 APPLICATION FEE IS NON-REFUNDABLE
DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O. Box 79399
'Z Dartmouth, MA 02747�' 17
., - ,...
' 508-999-0720 FAX 508-999-0738
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Zoning Review: Signature:
Date:
Energy Report: Signature:
Date:
Fire Chief Signature:
Date:
Board of Health: Signature:
Date:
Conservation Commission: Signature:
Date:
Other: Signature:
Date:
Description of work being performed:
NUMBER OF PLANS SUBMITTED:
1.1 Property Address: L �`� �z is ?o l Z
Nearest Cross Street:
Subdivision Name:
Total Land Area Sq. Ft.:
1.4 Water Supply (MGL c 40 5 54):
('Municipal ❑ Private Well
SITE PLAN SUBMITTED: ❑ yes 8 ho
1.2 Assessors Plat & Lot Number:
Plat Lot 2 -
1.3 Historical District ❑ yes trno
Has application been submitted to the Historic Commission?
❑ yes ❑ no Date:
1.5 Sewage Disposal System:
❑ Municipal 8 On Site Disposal System
'()UU _ «mt in (n— L.I,l—
-RESIDENTIAL
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1999
RESIDENTIAL
199c,
Company Name
Address
2.1 Owner of Record:
��
Name (print) Contact Address Phone Number
2.2 Authorized Agent:
Name (print) Contact Address Phone Number
3.1 Licensed Construction Supervisor: `Rpl A pl S U v� Not Applicable 0
Licensed Construction Supervisor License Number G
c,5! 3 J
Address 7 S o S Expiration Date
Signatu 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)
Registration Number (if none, state "none")
Signature
Telephone' Expiration Date
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:
Nome Improvement Contractors Registration, One .lshburton Place - Room 1301. Boston..gA 02108, (617) 727-8598
Owners Name (print)
Signature
by signing the above. the home owner acknowledees that there w"ill be no elimbiity to the Guaranty Fund
Date
=.4Homeoxvner Exemption One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR Ow'N PROJECT
109.1.1 Licensing of Construction Supen isors: Except for those structures eovemed by Construction Control in Section 116.0. effective July 1, 1982. no individual
shall be engaeed in direct) 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 entitle
Construction Supervisors. d Rules and Regulations for Licensing
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.
v. a 'H o me %cn er 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 famil, dwelling. attached or detached structures accessory to such use and/or farm structures. A person who constructs more
than one home in a mo-year period shall not be considered a Homeowner:
If you are applying under this section sign below:
Signature:
Your sienature carries certain responsibilities, including but not necessaril} limited to. general liabilitv
ccrzrrn`r:_ ncerv>,arnYn rill Dtznaneictn:ur.Drr fc+itantc A#Iann#i��##P
❑ new ❑ addition ❑ alteration repairs
construction*
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door
(shed/garage) no. of windows_ doors
* 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 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:
�� ►� tom, Fro R� I�2 bclr.5
❑ chimney/fireplace ❑ woodstove
❑ other ❑ demolition
(specify below): (speciA. below):
Item Estimated Cost (S) to be completed by permit applicant
1. Building I
.:.... <:.::
SRCTIO! 7B - fb1it }F#il ErTEttikt2E
I• 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.
Sig i under th ains and penalties of perjury.
n/T
r.s
Owner., Authorized Agent
Date