BP-62028SECTION 8 ' INSPECTOR'SREVIEWICOMMENTS'
1. Date plan reviewed: 2720
2. DENIED (see project review worksheet):
Date:
3. HOLD
Reason: Date:
Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Inspector's Signature: Dater ° VWWWW
.,AP.PLICAN.T
Applicant in
formed of above: Date
Cs�
Time: �� .Clerk. -
�
Comment s: .
7OX
O FIDE/INSP ECTOR S NO. TES . �. �.... _ .
Less �Application
Fee: $25A0 Remaining Balance: $
Total Permit Fee: $
Other
t $ Amount $
TOTAL FEE: Gross Area -New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to: &10rp-1 01W 01
SECTION 11._ ;ADDITIONAL COMMENTS/SKETCHES
❑ SPECIAL PERMIT (Per 780 CMR 111.13)
$2 5.00 APPLICATION FIKE IS WN BE -FEU .TTDPBLE A NON -'I BANT SFER AIBLE
DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENTILI
a �'� 400 Slocum Road, P.O. Box 79399
Dartmouth, MA 02747
Phone: 508-910-1820 Fax: 508-910-1838
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•... 1664 '�•'�
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www.town. dartmouth. ma. us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS:SECTION FOR OFFICIAL;USE.ONLY: ...}.
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RECEIVED BY
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DATE SENT FOR REVIEW h.
DATE IED `
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O K TO ISSUE SIGNATI)RE .DATE
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Zornng Distract �' � � Proposetl Use '� ' s Zone � � C ❑ B ❑ A LTV Aquifer Zone
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THE.:FOLLOWING.AGENGLES
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❑ Board of ,Boa of ; C] Conss q :pemo O,DPW' Energy Report
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K ;;: Appeals Health ;;» Commission Affidavit Card Sent . • ;:`• u '` Followyup,
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R>'" 't.F`^,rp "["XS S 1.e}\.;
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O Fire : q:Gas ❑ Planpin O Sewer Card L7 Wafer Card *,. p^ q Other
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REQUIRES'.FNSPECTOR'S. REVIEIN,BEFORETHE IS.Sl1ANCE OF,A;FERI(lIIT ,:,. .`
DEP,ARTMENTAL'APPROVAL
....
Zoning Review: Signature: Date: 27 ,
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other: Signature: Date:
Brief description of work being performed. i,,&pe% oo "o 9--pe a/=4C_y. J$ QAZ i Ale�ee%P�i
❑ CONSTRUCTION PLANS 0 SITE PLAN
❑ ENERGY REPORT
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction
-:wh s,.- ,...A- f.ca AnnGnA y of 7Rn CMR R5.2.15)
:SECTION2 = PROPERTY OWNERSHIP/AUTHORIZE
D;AGENT , '
2.1 Owner Record:
`�12tSTirU' SCh lar% of ��p Ss. f'T,4-e1��
-Y4FC` ;ells/-A-s,GesDX,
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
% ::SECTION 3 =CONSTRUCTION SERVICES -
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor: s 4# rA E & CA ig C
License Number: �7%�%
Address: 60' I��
Expiration Date:
Tele hone: 5-OF �g��Z�'�"O�OI
Signature: P
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? E es ❑ No
If No, go to the next section!
Are you clami g exemptiorl roir th, requirements? ❑ Yes ❑ No
x :;= If Yes, submit the required affidavit!
Company Name a .5 ^
Registration Number (if none, state "none"):
Address:
Signature: r Telephone:,]-71 ��'Q59,&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.
❑ 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 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.
which BuildingPermit i re uir 1;ha1 a exempt from the provisions of this section; provides that if a Homeowner
Exception: Any Homeowner performing work for hich a q P
engages a person(s) for hire to do such work, that such Homeowner shall t as smpervl
For the purposes of this section only, a "Homeowner is defined as folio s. P rson ho 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 d ached s ctur 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
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INSURA NCEAFFIDAVIT (MGL.c.1.52 § 25)
SECTION 4;_.WORKER'S COMPENSATION . ..
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure�to�ovide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: a" es ❑ No
`DESCgIPTION OF..PROPOSED°WORK' Check alt a pl!cable
( P )
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg.toofing/Siding ❑ Other
(Energy report required) .(Shed/Garage) (Specify below)
'❑ Addition ❑ Replacement 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.hs Unit 1
No of Bedrooms Unit 2 Nbhs Unit 2
ecify):
❑ Furnace (hot air) - fuel gas (natural or propane), fuel ele tri*�4h
❑ Boiler (heating) - fuel gas (natural or propane), fuel mil, elec ' ity, cify):
❑ HVAC (combined unit) - primary fuel, natural gas; propane, electiicity, other
❑ Air conditioning - (separate unit)
❑. None of the above to be provided
❑ Hot Water. Gas Electric Fuel Oil Other
Description of proposed.work: w i ao 04
ESTCMAT.EDCgNST,RUCTION;COST:.........., .3.,_..
Estimated Cost ($) to be completed by permit applicant -
Item
1. Building
�� r
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5 Total (1 + 2 + 3 + 4)
,
MSECTION 7A OWNER AUTHORIZATION�r;
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(fo:be completed: when owner's�agent`or dontractor:applies for.buiidtn
(Please Print) ,r
9 %'1� ►211 Ci4
I j� 6 p /�Mj.�., c h P ti as Owner of the subject property hereby authorize h� P& c
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
w SECTION 7B -_:OWNER/A UTHORIZED.AGENT DECLARATION
I, A, -CA /Zc-A , as Owner/Authorized Agent hereby declare that the statements and information
on the are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
ignature of Owner/Authorized Agent Date