BP-25741R F.CH)F.NTI A T ,
2002
SECTION 8-INSPECTOR'S REVIEW/COMMENTS
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: �.:
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A41A:.ems
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9. Inspector's Signature:
Date: J J
_ SECTIO ' 9- PP ICANT NOTIFICATION
Applicant infomTqd of above a Time: f� Clerk:
Comments: t A
r
SECTION 10- OFFICEINSPECTOR'S NOTES
Total Permit Fee: $ -T
Less Application Fee: S 25.00
Remaining Balance:
h
TOTAL FEE: l (Dl 1 Gross Area - New Construction total sq. ft. 7/t/9-
Gross Area - Alteration total sq. ft.
Permit Issued
SECTION 11 -ADDITIONAL CO\IMENTS/SKETCHES
✓
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MJ/ ° 33v
RESIDENTIAL 2002
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE
N y
DARTMOUTH BUILDING DEPARTMENT
DATE RECEIVED
�r 400 Slocum Road, P.O. Box 79399
Dartmouth, MA 02747
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEINIOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY:
BUILDING PERMIT
DATE SENT FOR REVIEW:
NUMBER:
DATE ISSUED:
OK TO ISSUE - SIGNATURE: DATE
Building Com sione�linspee-turofB digs
Zoning District:v ropased Use: Zone: B<"❑ B ❑ V Outside Flood Zone ❑ 'Aquifer Zone
THE FOLLOWING AGENCIES SHOU 'D BE NOTIFIED:
`
❑ Board of rd of Com. ❑ Demo ❑ DPW O Elec. ❑ Energy Report
Appeals Health Affidavit Card Sent: ...:Cut Off , -`Follow-up*
❑ Fire ❑ Gas ❑ Planning Board* ❑ Sewer Card ❑ Water Card - ❑ Zoning - 0 Other
Chief Cut Off / Cut Off / Cut Off :;Review*
* REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPARTMENTALAPPR V
Zoning Review: Signature: (% s Date:
�/J
Energy Report: Signature: Date: � � _Q�--
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�j04
Fire Chief: `A Signature: ��LG�rt e�y Date:
���C/O
Board of Health: Signature: L Date:Z— o z�
�Ul
Conservation Commission: Signature: V Date:
Other: Signature: Date:
Description of work tieing performed:
SECTION 1- SITE INFORMATION
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes ❑ no
(�
�S
1.2 Assessors Plat &(Lot Number:
1.1 Property Address: ���J C�S�s�2y T��
Plat % Lot �s -
Nearest Cross Street:
Subdivision Name:
1.3 Historical District ❑ yes ❑ no
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:
❑ Municipal❑ Private Well
❑ Municipal j5tOn Site Disposal System
o...... n D,... 11 10 IMM
C\brie-lornis\Bldgapp.res.wpd Pa.,e 1 Re anuary 19, 2001
RESIDENTIAL 2002 RESIDENTIAL 2002
SECTION 2 - PROPERTV OWNFRSHIP / AUTHORIZED AGENT
2.1 Owner of Record: "
i0a)RJ
Name (print) ��—
Contact Address Phone Number
12 Authorized Agent
1
!`a 1 k
2A
.
Name (print)
Contact Address Phone Number
SECTION 3 -CONSTRUCTION SERVICES
i l Licensed COIISn'tiCtiOn Supervisor:
Not Applicable ❑
Licensed Construction Supervisor e
License Number p SQ
[
Address 2hi�`�e�
Expiration Date
Signature Telephonesas 19�33i
3.2 Registered Home Intprot enaent Cc actor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to (7S0 CMR-6)? Xyes ❑ no
If no. go to the next section!
Arc you claiming exemption from the requirement? ❑ yes ❑ no
If yes, submit the
required affidavit!
Company Name e
Registration Number (i f none.. state "none")
Z 7 i 1 7
AddressVAv\ Ire1_ f
Signature - Telephone 56
Expiration Date a Q
3.3 For Residultial Remodel Wm k Only
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO SOT HAVE ACCESS TO THE GUARANTY" FUND:
QUESTIONS OR COMPLAINTS call or write:
Nome Improvement Cowractois Registration. Onedshhurtorr Placc- Room 1301, Bosrmt, .IU 02108. (617) 797-8598
Owners Name (print)
Signature
bv si_cninethe above, the home owner acknowledges that there will be no elicibilty to the Guaranty Fund
Date
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEO\\TERS ll'HO INTEND TO PERFORM AND BE RESPONSIBLE FOR TI IEIR M N PROJECT
109.1.1 Licensing of Construction Supervisors: Except for those structures govemed by Construction Control in Section 116.0, e f£ective July 1. 1982. no individual
shall be engaged in directly super isinz persons engaged in construction, reconstruction, alteration, repair, removal or demolition involdup Luc structural elements of
buildings or structures, unless he or she is licensed in accordance mitt the rules and reeuixions promulgated by the BBRS entitled Rules mid Rhculptions for Licensin_v
Construction Supervisors.
Exception: Any Homeowner perfomhina work for rohich a Building Permit is required shall be exempt from the provisions of this section: provides that if a
Hotneowtier engages a person(s) for hire to do such work, that such Homeowner shun act as sipenisor.
For the purposes of this section onh. a "Homeowner" is defined as follows: Persons) ho owns a parcel of land on which he/she resides or intends to reside, on
o hich there is. or is intended to be, a one or twn f an»h, dwelline, attached or detached structures accessory to such use andor tarn structures. A person who constructs
more than one [ionic in a two-year period shall not be considered a Homeowner.
If Nou are applying under this section sign below:
signature: _
Your signature carries certain responsibilities, includine but not necessarily limited to, general liability
NOTICE To LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction
Supervisor. tchedier or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15)
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL C 152 § 25)
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 - DESCRIPTION OF PROPOSED WORK (check all applicable)
new construction* addition ❑ alteration ❑ repairs ❑ chimney/ ❑ woodstove
renew report required) ("energy report required) fireplace
_ dec" ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ demolition
(shedlgarage) no. of windows doors (specify below): (specify below):
If new construction, please complete the following:
Single Family: no. of bedrooms no. ofbaths
Ta.o Family: no. of bedrooms unit l 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 of _ electricity, other (specify): ,e L- dt 1,
= HVAC (combined unit) - primary fuel, natural ,as, propane, electricity, other (specify):
= Air conditioning - (separate unit)
-None of the abot e to be provided
f Iot Water: Gas Electric X Fuel Oil Other
Brief Description of Proposed Work:
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (S) to be completed by permit applicant
1. Buildins
'. Electrical
Pllunbine
%ILchanical (HY'AC)
f. Total = (I -r 2 + 3 + 4)
x Estimated Total $ 50 O 6 6
SECTION 7A- OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(please print)
1, as Owner of the subject property hereby authorize
to act on nn behalf. in all matters relative to work authorized by this building permit application.
Sienaaure of 0%%ner Date
SECTION 7B - OWN'ER/AUTIIORIZED AGENT DECLARATION
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.
Si�ned under the pains an perjury.
7enalof
LZ -,2r/,2 � d
Signature ot'O%%t %Authorized Agent Dat
C bldg.forn1S 131deapp.res.w'pd Pace_ Rc, un mr% 19.'{101
Pagc 3
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Rev. January 19, 2001
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SONO-TUBE SIZE AND DEPTH
INSPECTION IS REOUMED BEFORE
THE COMSETE IS POURM
BUILDING DEPARTMENT
'town of Dartmouth
YOUR DRAWING LQJBT BE ?Vn
AT THE BUILDING DUS140 THE`.
PROGRESS OF THIS WORK.
BUILDING DEPARTMENT
Town of Dartmouth
FIRE STOPPINg REq'LJIIRFoVEd�T
Penetrations thru ratQd v.ral.s and floors shall be
sealed With a material capable of preventing the
passage Of flames, and hot nasSrS When SUbj xted
to the requirements of tho Text StandaW specific
for Fire Stops ASTM-E-814.
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DATE: REVISED
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FIRE STOPPING R Ot1IREfAENT
Penetrations thru rated walls and floors shall be
sealed with a material capab'.e of preventing thr,
passage of flames an f hot gasses when subjocted
to the requirements of the Test Standard specific
for fire Stops ASTM-E-814.
$ONO-TUSE SIZE AND DEPTH
l"I "ECTIVI IS REQUIRED suo:,E
THE CONCRETE IS POURED.
BUILDING DEPARTMENT
Tom V Daernot^
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STOPPIND' REQU1'4�
FIRS
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penetrations thru rated Wallis th
capable of preventing
sealed Witt, a material c� sc ected
pass,jge Of fiames and hot gasses vilijen sub!;- -r L- A� -
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for Fire Sto cavtz7j-r: POL-1r,
ENO -TUBE SIZE AND DEPTH
ni IN? ISS REQUIRED CEFORE
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r4 rj42 CUILDING DURING THE A Cvvy (Y ThLs Enecr;,7-1 THE CONCRETE IS POURED. 0 JJ -re--)
pr,ot,-4233 OF THS VJORK, PIFr; Must Be Kept 0,o Sim, BUILDING DEPARTIvir
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