BP-582921. Date plan reviewed:
2. DENIED (see project review worksheet):
Date: /i 11
3. HOLD t /ti ND/1 3 2099
Reason: Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Wt
«, _ SECTfQN iO"OFFICElINSPECTOR'S OTE NS =; o t
Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: $ / 5
Other $ Amount $
TOTAL FEE: 7s: Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
I Permit Issued to:
❑ SPECIAL PERMIT (Per 780 CMR 111.13)
$25.00 APPLICATION FEE IS NON RE -FUNDABLE R NON-TIIAINSFERABLE
pU TF/ F[�1�[ DATE RECEIVED
DARTMOUTH BUILDING DEPART ' ^'. i
400 Slocum Road, P.O. Box 79399
Dartmouth, MA 02747 q6T 2 1 �F 38
Phone: 508-910-1820 Fax: 508-91� C8Or
Energy Report:
Signature:
Fire Chief:
Signature:
Board of Health:
Signature:
Conservation Commission:
Signature:
Other:
Signature:
❑ CONSTRUCTION PLANS
Date:
Date:
Date:
Date:
Date:
Date:
Map -< Lot
1.3 Historical District ❑ Yes e No'
Has application been sybmitted to the Histonc Commission?
❑ Yes 0-40 Date:
❑ Municipal �n Site Disposal System
❑ SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construe'
SECTION 2 -PROPERTY OWNERSHIP /AUTHORIZED AGEN
T
r Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15)
2.1 {Owner 1Record:
\ 1 p
1{iGN Flrcr ��e✓1 r���% �� )^�r1��6�',
Name (print) ContadAddress Phone Number
2.2 Authorized Agent: \ _ t'r i a rJ ` - 1 P gao' Ar^ei kcjw Lr 1 ieg I'lwY
Name (print) Contact Address (M Phone Number
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor: 1 j) r 1, o y) � A i P � S � ' License Number: gj� L % a
Address: 52a 0M er C /L..� , u ✓1 />) W tv e6l f t-4 fvt (+ Expiration Date:
Q - i Signature: Telephone:-5j-63 7 r/ 79P / l�ql a0' f
!
3.2 Registe ome Improvement Contractor. Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? f les ❑ No
If No, go to the next section!
Are you claming exemption from the requirements? ❑ Yes ❑ No
1
If Yes, submit the required affidavit!
Company Name: >01 V) O r) S C6 r' O r Registration Number (if none, state "none"):
Addrer.s: �o R �fa ee ; CAly L?D -i w,054gcr4- W! A G L/ Ci
Signal re7 , f / ; i �%; Telephone: Expiration Date: /y ?6 to
3.3 For Residential Re�odel%ork 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
❑ I am a Homeowner performing all the work myself.
Owners Name (print):
Suture:
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
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 or 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 pedorming work for which a Building Permit is required shall be exempt from the provisions of this section; provides that if a Homeowner
engages a pemon(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 andlor fans 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 carves certain responsibilities, including but not necessarily limited to, general liability
i. SECTION 4-rWORKER'S COMPENSATIONINSURANCE AFFIDAVIT`(MGL & 152 § 25) .,
i. SECTION 4-rWORKER'S COMPENSATIONINSURANCE AFFIDAVIT`(MGL & 152 § 25) .,
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure top ide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: es ❑ No
-,SECTION 5 - DESCRIPTION OFPROPOSI D WORK (Check applicable) _'_ u.
17 Pool ❑ Repairs. ❑.Alteration ❑ Chimney/Fireplace oodstove/Pellet Stove
❑ Deck 40
❑ New Construction` ❑ Accessory Bldg. - ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage) - (Specify below)
❑Addition - ❑ 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
O Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
oiler (heating) - fuel gas (natural or propane), fu oil, lelectricity, other (specify): rJ C
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other
I i�ditioning - (separate unit) - -
❑ None of a above to be provided
Water. Gas �uel Oil Other
Electric
Description of proposed work: 054nli r-rreeStvitg[r pe(lef S(Oue
SECTION'6 ES7IMASEDCONSTRUCTIONCOST
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing -
-
4. Mechanical (HVAC)
U 0 1 GCS
5. Total=(1+2+3+4)
pNvtgO `SECTION TA "OWNERAUTHORIZATION
(to be completed when owner's agent or contradtot appiies for."buiidihd'per'mit)
(Please Print)
j %�Arc� eA y BC A 3� iel 5�
I, C 6 as Owner of the subject property hereby authorize r
to act on my behalf, in all rel tive to work authorized by this building permit application.
gmades
lo, at-�
Signature of Owner Date
`=sRSECTION 7B-OWNER/AUTHORIZED AGENT DECLARATION
1
r C kA t- H cA f 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 of perjury.
fizi&z /v-a (-G�1
Signature of Owner/AuthorizecbCgent Date