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BP-63851W5`CTiON8Y-JNSPECr.O, SREviEwicbroMENTS _ 1. Date plan reviewed: JUL 19 LY11 2. DENIED (see project review worksheet): 3. HOLD y� Reason: 4. HOLD subject to Zoning Board of Appeals action: Comments: Date: Date: Date: Inspector's Signature: Lg2z Data: JUL 19 20tt .. •t'.` C P 'Of2 . . .,_..i... 3-t.rr'L"^-.. T N n�OTIF.G,:TiON' Applicant informed o Comments: ov . : o Time: ilk UUU Clerk: Total Permit Fee: $ _ Less Application Fee: $25.00 Other $ Amount $ Remaining Balance: $ TOTAL FEE: Permit Issued to: �� Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. R 3 R' 4.3 r! r th RESIKEMRAM ❑ Approval in Part (Per 780 CMR.51 i 1.13) , 625_0A APP1,1VA TE0N F"EE 1S N®N RE-rU,i'DABLF & NOFtRO, n4,VSnRAMLE A, fAT:' "'^DAF- IVED 0�)' DARTMOUTH BUILDING DEPARTMENT 400 Slocum Road, P.O. Box 79399 Ii .L -8 AM 10: 13 Dartmouth, MA 02747 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 u :G Pl puiB R -, - - ODI GO t vJ OR S RE iE%N EFU"R DERA^n_.-IMENTRLAP "F:C Zoning Review: Signature: Date. JUL i J 10i1 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: 7em A,,e-4 7r,,7' 30 X3a' /vole 7enf r v10 Tar�c wn 7 ld.Wln 1.1 Property Address: ; 9-/11yS4QUM 1-'1J,1 f- )2erd Lot Area (sf.) Front Yard Side Yard Rear Yard Frontage Required Provided 1.4 Water Supply (MGL c40 s54): 11.5 Sewage Disposal System: [I Municipal ❑ Private Well ❑ Municipal ❑ On Site Disposal 1-1 CONSTRUCTION PLANS 1.2 Assessors Map & Lot Number: Map 7 Lot az, 1.3 Historical District ❑ Yes ❑ No Year Built ❑ Altering more than 25% per side of building Has application been submitted to the Historic Commission? ❑ Yes ❑ No Date: El SITE PLAN Page 1 Page 4 C E N C E (SJ d1A ��us�'�ce _Niea1i IOWA ' SECTION T''PRO`I-t•:''BRTY O!i NERS9(PIAUTHOR7ZEDy#G�',j,r„ 2.1 Owner Record: J4P1 es lqt-� Aah Name (print) Contact Address Phoef4umber 2.2 Auihorized Ag�s(�t `r arl &e-,yy I.LC- y,y� PC, 13QX yC Aie1 f74 paldt7�l, f,,7 02.779 Name (print) Contact Address Sav 7sTxsphone Number ��SS ... .:. 6 ON ff� CONSTRUCTION SERTL '.... , - ........ ..... 3.1 Licensed Construction Supervisor/Specialty License : License Number: Company Name/Contractor Name: .44Je Cgnc LLc Address: i?0. /3oK Ve _gAlle k y. I.4e7a �»k oJS R}'� M A Expiration Date: A/� / l ��- l � 2y Signature: "" "" —" Telephone:Ye8=[( 7t_ 3.2 Registered Home Improvement Contractor: Not Applicable ❑ Are you a Home Improvement Contractor subject to (780 CMR.11D.R6)? ❑ Yes ❑ Nc Are you claming exemption from the requirements? ❑ Yes ❑ No If Yes, Go to Section 3.3 Company Name/Contractor Name: Registration Number (if none, state "none': Address: Signature: Telephone: 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, 617-727-8596 ❑ 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 6108.3.6 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.8, 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 Constructim 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 them 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 Carnes certain responsibilities, including but not necessarily limited to, general liability i cECTiON'4- WORKER'S COWE,P,tS�I�jQN 1N5{%..�CE`?�� DAi�tT (Wr� Worker's Compensation Insurance Affidavit 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 ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Construction' ❑ Accessory Bldg. ❑ Roofing/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. 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 proposed work: OV)e 30 'X3a' r�(c 7en�' 7 t2 6J — lavlo �L u.,SECTIONs-iESVMATEI; oC sT eTioN-CO-0 . �,.4 _.. Item Estimated Cost ($) to be completed by permit applicant 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total=(1+2+3+4) . SECTION 7A OWNER:AUTHORIZA`nbu' # = r r -: orilpfete`cfvvhen owner`s agent orc©ntractor applies for bu fdingrpemltj"",.,.- _. (Please Print) I, as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date T 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. Signed under the pains and penalties of perof pel`u / 7/,11 Signature of Owner/Authorized Afent Date Page Page 3