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BP-28380RF.CIDFNTIAI 2003 2003 SECTION 8 - INSPECTOR'S REVIEW/CONIRIENTS I. Date reviewed:��1'a plan 2. 30 days to review period expires: 3. OK to issue date: 4. OK to issue subject to requested submittals(see project review worksheet): 5. DENIED (see project review worksheet): 6. HOLD reason: Date: Date: Date: 7. HOLD subject to Zoning Board of Appeals action: S. Comments: Date: 9. Inspector's Signature: - _ SECTI J 9 ;,A LICANT NOTIFICATION Date: (J Applicant inor dofab //���'�• Time: Comments: 11 Clerk: SECTION 10- OFFICEVNSPECTOR'S NOTES �^� Total Permit Fee�e:r$�r ©C,� Less Application Fee: S 25.00 Remaining Balance: TOTAL FEE:YY��JI, 00 Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. ft. Permit Issued To- � �x z z � c � "PCB SECTION 11 - ADDITIONAL CONINIENTS/SK�ETTCHES RESIDENTIAL ❑ FOUNDATIONONLY $25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE DARTMOUTH BUILDING DEPARTMENT 400 Slocum Road, P.O. Box 79399 / Dartmouth, MA 02747 DATE RECEIVED 508-910-1820 FAX 508-910-1838 APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING THIS SECTION FOR OFFICIAL USE ONLY RECEIVED BY: DATE SENT FOR REVIEW: 17 BUILDING PERMIT cc�� NUMBER: 02 J Q� DATE ISSUED: OK TO ISSUE - SIGNATURE: DATE Building nmissioner/Inspector of Buildings Zonimn District: Proposed Use: Zone: G1� B ❑ A ❑ V Outside Flood Zone ❑ Aquifer Zone THE FOLLOWING AGENCIES SHOULD BE NOTIFIED: ❑ Board of oard of ❑Con. Com. ElDemo ❑ DPW ❑ Elec. ❑ Energy Report Appeals ealth Affidavit Card Sent: Cut Off Follow-up* ❑ Fire ❑ Gas ❑ Planning Board* ❑ Server Card ❑ Water Card ❑ Zoning ❑ Other Chief Cut Off / Cut Off i Cut Orr Review* * REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT. DEPARTMENTAL APPROVAL Zoning Review: Signature: Date: Energy Report: Signature: Date: Fire Chief: Signature: Date: / Board of Health: Signature: Date: Conservation Commission: Signature: Date: Other: Signature: Date: ( Description of morA being performed: 1J —[7,c4ot avq SECTION I - SITE INFORMATION NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes ❑ no `� (q' �`� t^ v� !� \ 1.1 Property Address: j %V /tJ T �Cj�/ 1.2 Assessors Plat & Lot Number: Plat 1 H Lot_L�_- Nearest Cross Street: Subdivision Name: 1.3 Historical District ❑ yes ❑ no Has application been submitted to the Historic Commission? Total Laid Area Sq. Ft.: ❑ yes ❑ no Date: 1.4 Water Supply (MGL c 40 a 54): ❑ Municipal6Pr vate Well 1.5 Sewage Disposal System: ❑ Municipal 2'0n Site Disposal System r!NA, ­. -A Van.,. a RavJaauary 19.''001 C : bldc.l i'nns:6!d•_.Ipp.rts.\%pd Rev. January 19.2001 RECTT)ENTrAT. 2003 RESIDENTIAL 2603 - SECTION 2 - PROPERTY 0 RSHTPJAUTHORJZED ACENT 2.1 Owner Of Record:n/ I—.�9mq pmG �� MtSIJ iV) il�ht Name (print) Contact Address Phone Number 2.2 Authorized Agent: 13� kxs v-�$L l I woi� `f 6((_i-.9yi c r lg �J a � IJ 0I (11V 6010 03� 40 M Name (print) Contact Address Phone Number SECTION 3 - CONSTRUCTION SERvTCES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor ( ( PIG' License Number C)0!3 (J Address S �(� ExpirationDate rl 2 Signature Telephone 3.2 Registered Home Impronlement 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 0 M }e ( Registration Number (if none, state "none") Address (v� v�, , 1 aZj VA om Signature Telephone l �q l I Expiration Date 3.3 For Residential Remodel vork 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 - Roan 1301, Boston, MA 02108, (617) 727-8598 6:*,mers Name (print) Signature by signing the above, the home owner acknowledges that there will be no eligibilty 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 109.1.1 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individual shall be engaged in dimctly 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 mles 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: 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 mo family dwellingattached 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 NOTICE TO LICENSED 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 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (NIGL 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 (energy report required) (energy report required) fireplace ❑ deck ❑ pool 9'accessory bldg. ❑ replacement window/door ❑ other ❑ 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 I 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): ❑ A Ir conditioning - (separate unit) cY None of the above to be provided ❑ Hot Water: Gas Electric Fuel Oil Other Brief Description of Proposed Work: IVYl a (49- ' - SECTION-6 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (S) to be completed by permit applicant 00 1. Building J 2. Electrical 3. PlumbinL 4. Mechanical (HVAC 5. Total = (I + 2 + 3 + 4) Estimated Total $ ` SECTION 7A - OWNER AUTHORIZATION ` . (to be completed when owner's agent or contractor applies for building permit) (please print) p p 2]y!�G� , as Owner oft bject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION B- WNER/AUTHORIZEDAGF,NTDECLARATi N - - I 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. S g d and to ' s d enalties of perjury. �G Signature Owner/Au iorized lAgent ate O\MdeP,nr? Rev. January 19. 2001 <':'bldg. forns161dgapp.n•s.npd Pace 3 Rev. January 19. 2001