BP-36245RESIDENTIAL
❑ FOUNDATION ONLY
$2a_00 APPLICATION FEE IS NON.REFUNDARLE die NON-TRANSFERARr.E
2004
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1. Date plan reviewed:
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 Signature: Date:
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Total Permit Fee: $$
Less Application Fee: $ 25.00 Remaining Balance:
TOTAL FEE: J! 0 • L Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Pe t sue, To:
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RESIDENTIAL
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE &NONTRANSFERABLE
1' I 1
DARTMOUTH BUILDING DEPARTMENT
UA'ffi RECEIVI,D
400 Slocum Road, P.O. Box 79399 � �
- i „,� ;�: 116
;< Dartmouth, MA 02747
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
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Zoning Review: ;5�1,e Signature: Date /0 ,;IN
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:
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NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes ❑ n0
pJ�
N
1.2 Assessors P & Lot Number:
1.1 Property Address: I 2
jJ
Plat Lot
Nearest Cross Street:c3(
1.3 Historical District ❑ yes ❑ no
Subdivision Name:
Has application been submitted to the Historic Commission?
Total Land Area Sq. Ft.:
yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54):
1.5 Sewage Disposal System:
11 Municipal P�Pjivate Well
❑ Municipal AOn Site Disposal System
r
C:\bldg.foxms\Bldgapp.res.wpd Page 4 Rev. January 1, 2003
C:\bldg.forms\Bldgapp.res.wpd
Page 1
Rev. January 1, 2003
i 4 �
RESID+ENTIAT,
2004
RESIDENTIAL
2004
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2.1 Owner of Record:
rr tV lam} 1�o ry N (Zi
9 hoc Q3 , - 15-ca 63 6 91 s
Name (pint)
Contact Address .'Phone Number
2.2 Authorized Agent:
Contact Address Phone Number
Name (print)
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�Q�p/� ry �}� $.�}Tyj� j.y� j�+y�
3.1 Licensed Construction Supervisor:
Not Applicable ❑ -
Licensed Construction Supervisor
License Number -
Address
Expiration Date --
-
Signature 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!
Company 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) 727-85-98
Owners Name (print)
ignature
by signing the above, the 1 me owner a mowledges that there w be no eligibilty to the Guaranty Fund -- -- - -- - -
Date r%r°�(
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEO1A7JFRSWH0]NTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
109.1.1 Licensing of Construction Supervisors: Percept 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: Persons) who owns aparcel 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 dwelline, 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:
/
ignamre: �✓r%-�i�—�
Your signature 'es certain responsibili es, includmg but not necessarily limited to; general liability---
NOTICE TO I.ICF.NSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15)
* § � SECTION, 4— I*OkkEit'S*CONiPENSATION' II\SURANCEAFFIDAYI I (NIGL'"41$2
"a:Y
,. #a e`�wx:aX ba ns§o-rr'4ra ba+m tg}tl #9aa,.
Workers 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
'SECTION 5��IESCRIhTIbI\'�OF PROPOSED Yi ORK;(check,all applicable) 1. * b # #'ff
#xtlaX `- trux #-., w_n, ab n9r b9o-#.+ ....
❑ new construction* ❑ addition ?Ialteration Elrepairs ❑ chimney/ ❑ woodstove
(energy report required) (energy report required) ( fireplace
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other X demolition
(shed/garage) no. of windows_ doors_ (specify below): (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 (specify):
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
tt
Brief Description of Proposed Work: m Sc.� s ('Z TC2 .. 064 e- rJSu
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tl a r # e # . a t i o 4 i * ; is stcTaON.t GXFSTIMATEI) CONSTRU(;rIOTJ COSTS °+ i Q`''cr -a 4tV r iati yT Xcx°ir(1
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Item
Estimated Cost (S) to be completed by permit applicant
1 Rnildinv
2 Flertriral
4 Plnmhina
d Mrrhanirnl (HVAC)
5. Total = (1 + 2 + 3 + 4)
* Estimated Total 015000 a 0
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9 dwhen xt§0+d#4r4.4 §6$34.'a44hk#Y##rYx $9#..
* _ ` :, • a $ 9 � • $(lu Vie' c°btit�r�e�ed:when osmer's agent or�trntracior�p�ICe'k,�dc�iUitdiit�;Permtt� # »•• 9 * o-X.r �! > b +• r s t �o- v s a a
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(please print) `
I, (� N Z � `\y as Owner of the subject property hereby authorize Vie« � i�2
to act on my behalf, 1 all matters relatide to work' authorized by this building permit application.
Signature of Owner Date rT—
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+ a + u r � s,,• s .-a a-* # 4.-X � u � r �.r. a v atl � �44',�EI2%4�'FIIORIZED=ACAFivT DF.CI.rlR4TIC5h a !a € s.o- s s e #:-+ a e a a o a :+
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I. q r(C Mj hl crq Al as Owner Authorized Age! herebydeclare that the statements and information
on the regoing application are true and accurate, to the best o m0 no�wledge and belief.
Signed under the pains and penalties of perjury.
`
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Signature of OwneCr2Cuthorized Agent^` Date
) 3f?
CAbldg.fotms)Bldgapp.nes.wpd Page 2 Rev. January 1, 2003
CAbldg.forms)Bldgapp.res.wpd
Page 3
Rev. January 1, 2003