BP-58250- L-
❑ Approval in Fart (Per 780 CMR.5111.13)
1. Date plan reviewed:
2. DENIED (see project review worksheet):
Date:
3. HOLD �
Reason: A Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Inspector's Signature:
Applicant informed of above:
Comments:
I Total Permit Fee: $
I TOTAL FEE:
Permit Issued to:
Time:
Date: NUV 1 S Z M
Clerk:
Less Application Fee: $25.00 I Remaining Balance: $ �—
S Other $ Amount $
75` Gross Area - New Construction total sq. ft
Gross Area - Alteration total sq. ft.
r
521.00 A11PL1UXf1VN PEE 1J N7/N 11E•1J'UNJUAMILE OL 'i9' i[AIbLL'
r,n Rrt1 :;r I ATE EIVED
DARTMOUTH BUILDING DEPARTMENT
lu y: 400 Slocum Road, P.O. Box 79399 lr OCT 16 PH 2 58
Dartmouth, MA 02747
D�.-fiba: 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
THISSECTION FOR OFFICIAL USE ONLY
7-7
RECEIVED BY. / BUILDING PERMIT NUMBER
DATE ISSUED
DATE SENT FOR REVIEW �_
O.K. TO"ISSUE-SIGNATURE:`. z c� " "' DATE
Zonmg Distnct Proposed Use = Zone'[YC ❑ B C] A O V " Aquifer Zone"`
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED.:
"� Board of.,;,fir❑ Board bf ❑ Cons _❑ demo ,D DPW - O Elec m:Energy Report; n
'"Appeals "'Health; ,-`:Commission`.�� P.ffidavd `Card Serit Cut Off `i , 'Follow up '.." =<
❑ Fire ❑Gas "�:t7 Planning ❑Sewer Card ' O Water Card : O Zonmg ❑Other �;'�`
"Chief Cut Ofi Board = ` , Cut Oif CutbB =^ -
`..*REQUIRES INSPECTOR'S'REVIEW;BEFORE THE ISSUANCE-OFA PERMIT.
ARTMENT APP. VAL= ."
11X4Zoning Review: Signature: Date: Nov r a aum
Energy Report: Signature: Date:
Fir Chief'. Signature: Date:
Fire
Board of Health:
Signature:
Conservation Commission:
Signature:
Other:
Signature:
Brief description of work being performed:
1.1 Property Address:
Lot Area (sf.)
Front Yard
Side Yard
Rear Yard
Frontage
Required
1.4 Water Supply (MGL c40 s54):
❑ Municipal ❑ Private Well
Provided
Date:
Date:
1.2 Assessors Map & Lot Number:
Map % Lot o2
1.3 Historical District ❑ Yes ❑ No
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
1.5 Sewage Disposal System:
❑ Municipal ❑ On Site Disposal System
e CONSTRUCTION PLANS ■ SITE PLAN 1:1 ENERGY REPORT
=SECTION2 - PROPERTY OWNERSHIP/AUTHORIZED`
AGENT..
2.1 Owner Reco d:
I
Name (print)
Contact Address Phone Number
2.2 Aghpirized Age % /
�Ail�i l/
077
Nam6-(pnnt)
Contact Address Phone Number
SECTION 3 =CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor /Specialty Licen a
Not Applicable ❑
Licensed Construction Supervisor /Specialty License -
License Number: % 52 zos
Addres .. -�; I -e--
Expiration Date:
Sign ure: lephone:
J3.2
Registered Home Improvement ntractor.
Not Applicable ❑
Are ou a Home Improvement Contractor subject to (780 CMR.110.R6)? ❑ Yes ❑ Nc
h%
k
If No, go to the next section!
Are y claming exemption from the requirements? ❑ Yes ❑ No
JIf
Yes, submit the required affidavit!
Company ame: -e 7
Registration Number (if none, state "none"):
Address:
(00 (�
Signature: Telephone: l`
Expiration Date: ® '
3.3 For Residential Remodel Work my
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
❑ 1 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
5108.3.5 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1082, 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 ofthis 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: 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 family dwelling, attached or detached structures accessory to such use and/or fans 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
SECTION 4 -WORKER'S COMPENSATION INSURANCE AFFIDAVIT ,(MGL c 152 §'25)
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to p� de this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: IYYes ❑ No
SECTIONS = DESCRIPTION OF PROPOSED WORK (Check all applicable) "
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction` ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage) (Specify below)
❑ Addition 176placement window/door ❑ Demolition
'Z1i)
(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:
l a
- SECTION 6 -'ESTIMATED CONSTRUCTION COST 0-
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total =(1+2+3+4) V O
s- SECTION 7A - OWNER AUTHORIZATION,
(to be completed when owner'agent 'or contractor applies for building permit)
(Please Print)
I, as Owner of the property hereby authorize
to act on my behalf, in all matters relative to work But on ed ilding permit application.
Signature of Owner Date
:. [SECTION 7B - OWNER/AUTHORIZED AGENT:DECLARATION' '
i
I, as Owner/Authorized Agent hereby declare that the statements and information
o e foregoing application arsKrue and accurate, to the best of my knowledge and belief.
n d under the pains d p Wallies of perjury.
gnature of Owner/Authorized gent D to I I