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BP-28654RESIDENTIAL 2003 SECTION S - INSPECTOR'S REVIEW/COMMENTS - - l. 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): 5. DENIED (see project review worksheet): 6. HOLD reason: Date: Date: Date: 7. HOLD Subject to Zoning Board of Appeals action: 8. Comments: Date: 9. Inspector's Signature: Date: CTION 9 - APPLICANT NOTIFICATION Applicant informed of above Date: Time: Clerk: Comments: SECTION 10- OFFICE\1NSPECTOR'S NOTES Total Permit Fee: S1:5_01 C)o Less Application Fee: $ 25.00 Remaining Balance: $ �,j; Q0 TOTAL FEL�0 De) Gross Area - New Construction total sq. ft. h , G-te Gross Area - Alterationtotalsq. ft.. -- Permit Issued To. q64'.'/ le-1l' [,n'1 C Yee, T'/ 0r'1 SECTION 11 - ADDITIONAL COMNIENTS/SKETCHES RESIDENTIAL 2003 ❑ FOUArDATIONONLP $25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE DARTMOUTH BUILDING DEPARTMENTpAIRECEI�' 400 Slocum Road, P.O. Box 79399 0011 U¢V/� xlDartmouth, —` �.;I l�� 33 MA 027472s (d•a 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: BUILDING PERMIT DATE SENT FOR REVIEW: NUMBER: DA SSUED' OK TOISSUE- SIGNATURE: tbs4TE ��/� O3 Building Commissioner/) ctor of Buildings Zoning DistrictS+et3 Proposed User Zone: C ❑ B ❑ A ❑ V Outside Flood Zone ❑ Aquifer Zone .� THE FOLLOWING AGENCIES SHOULD BE NOTIFIED: ❑ Board of ❑ Board of ❑Con. Conn. ❑ Demo ❑ DPW 0 Elec. ❑ Energy Report Appeals Health Affidavit Card Nt: Cut Off Follow-up* Water ❑ Fire ❑ Gas ❑ Planning Board* ❑ Sewer Card ❑ Zoning ❑ Other Chief cutoff / Cut Off / Cut Off Review* " REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT. DEPARTMENTAL APPROVAL Zoning Review: Signature: Date: Energy Report: Signature: 4n Date: ature� Date: Fire Chief: S(.: Board of Health: S- Date: Conservation Commission: Signature: Date: Other: Signature: Date: Description of mark tieing performed: SECTION 1- SITE INFORMATION NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes ❑ no 1.2 Assessors Plat & Lot Number: I.l Property Address: i, �iisn'tavM PoIN7 eD, Plat Lot ZZ -J_ Nearest Cross Street: SIA%I-tf/ NECK ��• 1.3 Historical District ❑ yes ❑ no Subdivision Name: 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: ❑ MunicipalFPrivate Well ❑ Municipal O'On Site Disposal System C:,bldc forms\Bldgapp.res.,pd Vooe 4 Rev. January 19. 2001 C_\bldg.lbims\Bld�rpp.res �cpd Pace 1 Rev. January 19, 2001 RESIDENTIAL Innll SECTION 2 - PROPERTY OWNERSHIP / AUTHORIZFD AGENT ' 2.1 Owner of Record: LVIC fFRN,4AIPO LEi105 6 TOWN 20t FE DP, hOY- 9 f 7-�/83 Name (print) Contact Address Phone Number 2.2 Authorized Agent: R01W-7 itNTHDN`/ f}tv7i/DNY 0 AaC C,Og-4y2 36G2 Name (print) Contact Address Phone Number SE TiON3-CONSTRUCTION ERVf ES 3.1 Licensed Construction Supervisor. agep-7 / ^17H0~%z Not Applicable ❑ Licensed Construction Supervisor License Number QS �s�i0 Address ' " D CFI G✓ODj% Ilet Expiration Date /2/�/� oo+f Signature G�cZ Telephone spp` 9 f2-316Z ered Home Improvement Contractor: Not Applicable ❑ Home Improvement Contractor subject to (780 CMR-6)? ❑yes ❑ no .If no, go to the next section! aiming exemption from the requirement? ❑ yes ❑ no If yes, submit the 6ement, required "affidavit! Name Registration Number (if none, state "none") Telephone Expiration Date .sidential 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 Date by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund 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 I, t 982, 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 roles and regulations promulgated by the BBRS entitled Rules Regulations Construction Supervisors. and for Licensing 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 Homeowner such 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 dwell_ ine, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-yearperiod shall not be considered a Homeowner. Ifyou are applying under this section sign below: Signature: Your signature carries certain responsibilities, including but not necessarily limited to, general liability y RESIDENTIAL 2603 NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction Supen isor, 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 ❑ deck ❑ pool ❑ 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 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�,o)her (specify): 11 HVAC (combined unit) - primary fuel, natural gas,pnSpane�electricity, other (specify): Air conditioning - (separate unit) Ci None of the above to be provided 11 Hot Water: Gas Electric Fuel Oil Other Brh,fDeseriptiotr of Proposed Work: /USTf1ZLA7i0v O� yOUst Gfr�st v� Dv vrJr�TioAl s>r- " SECTIONQ- ;ESTIMATED CONSTRUCTION COSTS Item Estimated Cost ($) to be completed by permit applicant I. Buildin 2. Electrical 3. Plumbin 4. Mechanical HVAC 5. Total = (1 + 2 + 3 + 4) * Estimated Total, s , a SECTIdN 7f1-OWNER AUTHORIZATION - (to becompleted when own4s agent or contractor applies for building permit) (please print) e -!, ' 1 Q D P 12 `- Wl 0 --7) as Owner of the subject property hereby authorize �f1U IIIW14 AI U>E to act on (ny behalf, in allmatters relative to work authorized by this building application. permit Signature of Owner Date SFCTION 7B - OWNER/AUTFTORIZED AGF,NT DF,CLARATiON I, �Ol3 7 /ilW nTh N 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. Signed under the pains and penalties offfperjury. "'`�[;�✓G-tTA7 1N7"19d1^f fG✓/f�7E 10 S/Z ©� Signature of Owner/Authorized Agent Date C:\bldg.foons\Bldgapp.res.Wpd Page 2 Rev. January 19, 2001 C:\b ldg. fo mis\Bid Capp. res. W rd p—, n t ; loll f1 i I i C — I I ►� �Ms ( T) p��.l�-----j--- -- or aw, I \ h' T M Gam( �� Pots I i _—lo �oWNl�lohl x II II I, �11„xlZ,, 7� 1 1 I 1 � t P ! _ X I I'/� � I �I I� I 7 - I I /�\ I � X I I ��2j � p ,y I, kliA X ( L—. i I 1-- f I I I I , a I i I 0 —_ - - fir" -omaN I I t Itr T�IJ Imo— I I _° r, 2103 r,A 2 �s'i (! 32 N T C E i An A3 B"uv.:Pv musk be Stti:?nittc t0 �i1 :udiri� Dept- prior to caLia for a foundation inspection or any further construction YOUR DRNNING MUST BC rCF'I AT fHE BUILDING DURING THE PROGRESS Of THIS WORK HIIILD111C; DJ,?ART,-,r3rr7T Tc-n Q: 4 9. �7,r7d ii rcc D { l.L,',l A Copy Of This Endorsed Nan N"lust Ge Kept On Site During onstruction Dzte