BP-55561SECTION - INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed:
f8
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2. DENIED (see project review worksheet):
3. HOLD
Reason:
4. HOLD subject to Zoning Board of Appeals action:
Comments:
Date:
Date:
Date:
Inspectors Signature:
Date:
SECTION 9 -APPLICANT NOTIFICATION
Applicant informed of above:
Comments:
Date: Time:
Clerk:
SECTION 10 -OFFICE/INSPECTOR'S NOTES
Total Permit Fee: $
Less Application Fee: $25.00
Other $ Amount $
Remaining Balance: $
TOTAL FEE: 76 Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
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SECTION 11-ADDITIONAL ' COMMENTS/SKETCHES
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RESIDENTIAL ❑ Approval in Part (Per r80 CMR.5111.13)
S25.011 A1I•1'I.I(;A'l'10,% WEE IN iNON I915-1'UA1.auo.0 n rr ■�i�-■■itu�,r r.■aeusa ■
DATE RECEIVED.=J
:MUTH\
aF� � DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O. Box 79399 ;" t r;•,
T ' Dartmouth, MA 02747 " 1 : 2q
Phone; 508-910-1820 Fax: 508-910-1838
www.town.dartmouth.ma.us
APPLICATION TO CONSTR CT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
Zoning Review:
Signature:
Date: 1/4
Energy Report:
Signature:
Date:
Fire Chief:
Signature:
Date: _
N40 J
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Board of Health:
Signature:
Date:
Conservation Commission:
Signature:
Date:
Other:
Signature:
Date:
Brief description of work being performed: E
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SECTION 1 -SITE INFORMATION
1.1 Property Address:
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2�/Offl0"
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IFO-riAP
1.2 Assessors M p & Lot Number:
Lot Area (sf.)
Frontage
Map Lot
Required
Provided
Front Yard
1.3 Historical District ❑ Yes X No
Side Yard
(
Has application been submitted to the Historic Commission?
Rear Yard
❑ Yes ❑ No Date:
l
.4 Water Supply (MGL c40 s54):
7.5 Sewage Disposal System:
❑ Municipal
r
AI Private Well
❑ Municipal XOn Site Disposal System
❑ CONSTRUCTION PLANS
❑ SITE PLAN ❑ ENERGY REPORT
2
SECTION.:2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT <;
1 Owner Record:
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Name (print)
Contact Address Phone Number
2.2 Authorized Agent
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3453 r�t/��7'PDiPT �? �9 ti
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Name (print)
Contact Address Phone Number
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SECTION 3- CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor: DAVIDLicense
Number:
Address:
/ b
Expiration Date:
0 /91c3
Signature: Telephoner 6s6,0
3.2 Registered Home Improvement Contractor.
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR.110.R6)? t Yes ❑ Nc
If No, go to the next section!
Are you claming exemption from the requirements? ❑ Yes V No
If Yes, submit the required affidavit!
Company Name: V, W. HOMEE
Registration Number (if none, state "none"):
0
Address: I I D �� �� / >=SJ %IA,46,171d./
Signature:
Telephone:777 7M 2
Expiration Date: 07 6
3 For Residential Remodel Work Only
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
C.- STIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration, One Ashburton Place - Room 1301, Boston, MA 02108, 617-727-6598
❑ 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, 1982, rw 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: Pemon(s) who owns a parcel of and on which he/she resides or intends to reside, on which
there is, or is intended to be, a one or two (amity dwelling, 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:
Signature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
G�'
- 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 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)
❑ Deck ❑ Pool Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction' ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage) (Specify below)
❑ Addition 1 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 X
❑ Hot Water: Gas Electric Fue Oil Other
Description of proposed work: P IRNID REtPLAct VvJMDaW w1
A N 'P . I V
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id SECTION 6'- ESTIMATED CONSTRUCTION COST - '
Item
Estimated Cost ($) to be Completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanic. r/7
x
5. Total=(1+2+3+4)
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SECTION 7A - OWNER AUTHORIZATION
(to be completed when owners agent or contractor applies for building permit)
(Please rmt)-
fj V- l/_(A -r iFY t— , as Owner of the subject property hereby authorize 6^7U
to act on my behalf, in all matters rel/atitive to work authorized by this building permit application.
re of Owner ate
:SECTION 7B-OWNER/AUTHORIZED AGENT DECLARATION ..
as6+vnet/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 c erjurf.
Fy^1\Y�J
i nature of Owner/Authorized Agent Date