BP-23167RESIDENTIAL
2002
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 workshect):
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:
Date:
SECTI 9 - APPLICANT NOTIFICATION
Applicant info e f ab ve Date Tim : � Clerk: I
f% v
Comments: �"
.
..
SECTION 10- OFFICEVNSPECTOR'S NOTES
Total Permit Fee: S
I Less Application Fee: S 25.00
Remaining BalancL
TOTAL FEE: Gross Area - New Construction totals ft.—
iv q o2�O
Gross Area - Alteration total sq. ft. Permit Issued To' ,/-
,, a
SECTION I I - ADDITIONAL COMMENTS/SKETCHES
-a
�T-�--
RESIDENTIAL
0 FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE
--DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT
r 400 Slocum Road, P.O. Box 79399
^ t� ,
to ;`"'
Dartmouth, MA 02747
15 i � " 1. 26
='Y 508-910-1820 FAX 508-910-1838
APPLICATION TO C 'STRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY:
DATE SENT FOR REVIEW:
BUILDING P
NUMBER:
DATE ISSUED:
OK TOISSUE- SIGNATURE: DATE FEB 2 5 2002
u' ding Commsssione /Inspetor of Buildings
Zoning District: Proposed Zone: -N❑ B ❑ A ❑ V Outside Flood Zone ❑ Aquifer Zone
TILE FOLLOWINGAENCIES SHOULD BE NOTIFIED:
❑ Board of oard of pro/n. Com. ❑ Demo ❑ DPW ❑ Elee. ❑ Energy Report
Appeals Health Affidavit Card Sent: Cut Off Follow-up*
❑ Fire ❑ Gas ❑ Planning Board* ❑ Sewer Card ❑ Water Card ❑ Zoning ❑ Other
Chief Cut Off / Cut Off / Cut OH Review*
* REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPARTMENTAL APPROVAL
Zoning Review: Signature: Date:
Energy Report: Signature: Date:
Fire Chief: Signature: I Date: _
Board of Health: Signature: Date:
Conservation Commission: Signature: I Date:
Other: Signature: Date:
Description of Ivork behkq performed: .
SECTION I - SITE INFORMATION
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes ❑ no
I.1 Property Address: J
1.2 Assessors Plat $ of Number:
Plat Lot �_-
Nearest Cross Street:
Subdivision Name:
1.3 Historical District ❑ yes ❑ no
Has application been submitted to the.Uistoric Commission?
Total Land Area Sq. Ft.:
❑ yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54):
1.5 Sewage Disposal System:
❑ MunicipalO Private Well
❑ Municipal ❑ On Site Disposal System
C:Abldg. formsVBIdgapp.res. wpd Page 4 Rev. January 19.2001
C\h Idy.l'ortm\Bldgapp.res.wpd
Page I
Rev. January 19, 2001
RESIDENTIAL
2002
L
RESIDENTIAL
2002
SECTION 2 - PROPERTY OWNERSHIP / AUTHORIZED .AGENT
2.1 Owner of Record:
►�f1 I?I� }�R <
NCOKL. rN( NY WO 7/5-)S' 3y
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
'T4m��i��i�
��lf�'�
Name (print)
Contact Address Phone Number
SECTION 3 - CONSTRUCTION SERVI ES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor (AMt( CgIL Plr
License Number lo
Address M'
t3I !
Expiratiop Date
c03103
Signature
jk Telephonel�� �p-07
3.2 Registered Home Improvment 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 O 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) 727-8598
Owners 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 OwVN PROIECI'
109.1.1 Licensing of Construction Supervisors: Except forthose structures governed by Construction Control in Section 116.0, effective July I, 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 lie 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: 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 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 (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
(energy report required) (energy report required) fireplace
bd'deck ❑ pool ❑ accessory bldg. ❑ replacement window/door Cl other ❑ demolition
(shed/garage) no. of windows doors (specify below): (specifv 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
Brief Description of Proposed Work:
ti
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (S) to be completed by permit applicant
I. Buildin
1. Electrical
3. Plumbin
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4)
* Estimated Total 3
SECTION 7A- OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(please print)
I, as Owner of the subject 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 7B- OWNER/AUTHORIZED AGENT DECLARATION
I, o , 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.
0
S i d u e t t lties of perjury.
Asd
l ^
[/IDate
Signatt_ 'Owner/Authorized lgent
C°bIdg. formslBldgapp.res.riTd Page 2 Rev. January 19. 2001
C:`,bldg. fbnus,Bldgapp.res. wpd
Page 3
Rev. January 19, 2001
*r f v
-
i G1
, >.. .: ._ . •. "k ^''CA'Scr-2 -.. . LrN£.-i Y.r X i.`rd `3' i-�F F 'ALL :�'�;: �R� ,:3 Ax d .E 1 i.fa ' wl .A..`L ��i. =R':,.is ,N..:
r4-:�
.. -'. _ - _ ., x '• ... _,. ....,.... a 'a. ,:•i' . ,-Z'? .. r. .. x.- R '>: `.� <4 �:�+x �`m • a i -'d is dr -. ..r . .a L ^. N.r\v �. . z'_ ;�. .
,.. .... , •.:. ,_,f,: a_...:� K }.vP siy: .� �. b.., �. s. ..;, :. al .._ -. ... � ve �tM}. 4- 4 h�.... "kL.
-..>.
-.Vf7
I,. 4i� :. k � $g.. =8.r s., sj •.>' }i ,�".(„'
[/Jy S
.. p.- -.. ':,. r. .. - b .:. ...... ... . c-�: , 't:,: .:. �_ ... '4 "r,;. if T.=•-kf e'-�1 `Yra ,a� P a t ,.�
...:.:. � .:..-<. R \..:.r- .. _.C, .:.. .. �c-.. ,. 7.' 'f`L ...F i .a� r a'Fra ��-r... .F �;�n,1._ .+. tl✓G� -f Sy -;d,. .l#Ir":
... a ..,..... .. -..- ♦ �. �.. -o. _s .:-'j 3 .:}.-, ..- .. .... :`a.. ,.. y... � l�k i5�\ •\.' /R _N4 �=r.� '•`�h.. (, `J.ac:
nl ,' . � \` \. :`« .. •. • .. « � .._ :.: f r :: . '�P t t w� {[a nL A Y A`. Y"A..-w. X - Y.. }fix !'SY! 1/
':(y
, :.l4,... .t°. 4>d;
•" -'. Y... i ..:: .- --, -x ._ :..._, •. _• ..., ,_: x ti f ',,t Y } _ �;-. Y''-':Y vim. '.��c.` i+k.t�•.so:r•-
Yo
- .. _.. � � „�.... , ..',.. •.. .. .... .. , • .' -,,. . �. .. ��..z � "a f _ r - 1-�;n ,y , y#'s a ..E -' rt ._d i<..«
"� r ��, l .i:� � Ii VA J-Y C"' l �J�t—•O \'Y f�-il C .. �. i-;:F v '7 ` y s _
. -. ....t _- ..,, •. - :" k •. 'I.._r _f3 fy t _ ,,y,�- p st !E x\ris.••'w v4ifr`t{ T.r? y—c
••I,K�( `A- ///�If`��1I J / y1( _ I .l Y . �uN4
V I 1 `V ll...��.• Ca i lrC A �`C3 ..Y.
1
oo
. .S
iT zJ s
DaSUNG CONCRETE FOUNDATION z
ELEV=i'34.05 (NGVD)
i
�. ifj�.� � 4<: fi + �' F _ � y y' u� Y - .. . } r ' 'r a ' �t+e, "9' # a .i v y 3 •'
• Iv
III1777J"' Jvi, j
,
' r
3 •,f
............. ..... 7
N
V N
- k
CL
J �
� x
A t 1L
B.M. 112: / 1 r t
- - ` - - - NAIL SET AV16R' OAK —J J :..`,:
. a ,... 3 NC
Q£V= 3L 2 (yp)
K .TOWN bF DAR
ECOR�
Y -
`A'CoP �.F
a or
--Plan M6jtr'Bb, Key
r
15 Duri
= Dat`,4
NAILSET M! 14" OAK'
N %• [ EIEV,= 30.3E (NCVD) r
plffg4k V
LA �V. -t�_
�12V_2 ..- I._.. .. � �Y. t.
X.�r .';�Lll �'
_4 _771
1z,
k
<7
M,
U t�z �N'
W
u
lk
7�
ON
u
F_� - I Nb
_�T
-EVSTING CONCRETE FOUNDAT70N
AEV
�24 0
k:(NGVD)
All
FILE COPY.
70
-7
_7v o4
Ji ri p Y. U I T thi s I n d
c�
pi �l Sitt
'19 Mint DO Fed, C
Durin
-- ----------
B. M. //2:
NAIL SET AV lW' OAK
ELEV.- 3t32 (MGM)
0FDAf
is
. . . . . . US e- Ke
u
ate-
15
B. M.
NAIL ��Tw ws oAK
nEV.- 30.36 (MGM)