BP-11891Residential
lV Sk,a�I �r e�
1999 Residential
❑ FG✓l.'O/TIONONLY
1999
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:
8. Comments:
9. Inspector's
Applicant informed of
Comments:
Total Permit Fee: S I Less Application Fee: S 25.00 I Remaining Balance: S-4 2 I
TOTAL FEE: Gross Area - New Construction total sq. ft. -177' 2
Gross Area - Alteration total sq. ft. J)
Permit Issued To / IV_ l��a� t n �— Cci1 r f
15-
i� T" DARTMOUTH BUILDING DEPARTMENT DATE REC 1VED ^ `'
P , T
_ 400 Slocum Road, P.O. Box 79399 )
to
Dartmouth, MA 02747
`�f.:a"^<.:%i', 508-999-0720 FAX 508-999-0738 -
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Zoning Review: Signature: l� Date': _
Energy Report: Signature Date:
Boa Chief: Signature: Date:
Board of Health: Signature: Dater
conservation Commission: Signature: 0A Date:
N MBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes ❑ no
1.1 Property Address: �+ 1.2 Assessors Plat Sa Lot Number:
earest Cross Street Nl l Tt� N/ZC%C n D t Plat Lot
.��-
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:
❑ MunicipaoK Private Well v ❑ Municipal M On Site Disposal System
n
Name (print)
Contact Address
�0(
c:`,wpwin\forms\bldgapp.res Pale 4 January 20, 1999
c:\wpwi n\forms\b I d gapp.res
Page 1
January 20. 1999
Residential
1999 Residential
IJ
2.2 Authorized Agent:
Ia
(}YTirT
Contact Address
&
Name (print)
Telephone
SEC7TON $ �CdNSTRUCTiflYSFRY 10ES
3.1 Licensed Construct Supervisor
Not Applicable Li
`
Licei�gd ConsonS ervisot �,�}
6 i
License Number
Address\') vI i
r/
W� C ` o (
°
Expiration Date
[gnat I"-
0.
Telephone
3.2 Reg tered o C provement ntractor.
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ yes O no
no, go
Are you claiming exemption from the requirement? ❑ yesf ❑ noto the next sectionl
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
'ERSONS 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
0-. 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 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: 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
1999
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)
Workers Compensation Insurance affidavit must be completed and submitted with this application. F�''lure to provide this affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ;vel s ❑ no
❑ addition ❑ alteration ❑ repairs
construction*
❑ chimney/fireplace] woodstoye
❑ deck ❑ pool VS accessory bldg. ❑ replacement window/door ❑ other
(shed/garage) 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 9 no. of baths unit 2
Brief Description of Proposed Work:
J
❑ demolition
(specify below):
Item I Estimated Cost ($) to be completed by permit applicant I
_�. lotal=(I+2+3+4)
* Estimated Total
(please pr III)
I, T> C as Owner of the subject property hereby authorize
to act on my beh , 'n all matters relative to work authorized by this building permit application.
ISignature of Owner Date
Imcm uru,&Fyjg , as Owner/Authorized Agent hereby declare that the statements and information
foregoing application are true and accurate, to the best of my knowledge and belief
under the pains aycj penalties
W C
arized Agentif Date
c:\wpwimformslb ldgapp.res Page 2 January 20, 1999
c:lwpwi n\form s%b I dgapp. res
Page 3
lanuory 20, 1999
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28(o TEST PIT jl
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STATEMENT
MENT REQUIRED 7 i8 14 to 1 1 \, `t }\ , \ �1 ! t ELEV, 31.3E .� . •Oo
THHEe STATEMENT REQUIRED ts:r' \ y 1 k s� g LOAM
TIN e`� LT \\iI. vr.../ W ,J �\ ' IIOd"1 MED. Co^Rse
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hf� "."stem � is Not Designed �/
F `'age Grinder, Whirlpool -- � `X,N TABfE ro= nA
OTTOcv PEBfIOL
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PERCOLA71ON BATE
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:a B£nt+IrNxx: @S b �Lmypt
TIC IdS MUST NOT BE I10116kT u °�wr 3
'IutGED WITHOUT BOARD r
OF HEALTH APPROVAL — Lvr IS'S F2Ar7-
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LOT Jr-, 9L*r11
ENGINEERS AHUILT
PLAN &CERTIFICATION
STATEMENT REQUIRED
",.,-tern is Not Designed
-nge Grinder, Whirlpool
:igh Water Use Devices.
fIONS MUST NOT BE
:i »ED WITHOUT BOARD
OF HEALTH APPROVAL
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ROTMY OF PLRCLOLATION
TEST HOLE:
PEW0LA7?CN RATE:
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