BP-59712Inspector's Signature:
Applicant informed off
Comments: _ _C /
(/ Time:
Less Application Fee: $25.00
Total Permit Fee: $ �b
Other $ Amount $
TOTAL FEE: Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
Date: APR 3 0 2010
Remaining Balance: $ "
����®������ ❑ Approval in Part (Per 780 CMR.5111.13)
rnn &,PvAr4Lr `1r0N FEW TV NON R1F.->f U1%MABLE & NON -TRANSFERABLE
DATE RECEIVED
DART UTFi BUILDING DEPARTMENT,
00 Slocum Road, P.O. Box 79399
Z _ Dartmouth, MA 02747
APR 2 0 N1 2: 58
hone: 508-910-1820 Fax: 508-910-1838
'•.....
1664 .�
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
:THIS`SECTION'FOR;OF.FICIAL' USE,ONLY a 1
li
'
BUILPING`PERMIT NUMBER
RECEIVED BY
!
DATE SENT FOR REVIEW
DATE ISSUED
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2
SIGNATURE A DATE
,O K TO ISSUE
r,Y T 5IN
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,.'SFr •a.+T'
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Zoning Distract Proposed Use Zone 0 C ❑ B A ❑ V Aquifer Zone q;
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i __ . r ., s F - -y t e 5 . s -e:
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may,,-�.,,.,r•.-."-r"^'"r!•.^`"
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THE:FOLL0INING AGENCIES SHOULD BE NOTIFIED _
{' `❑ ❑Board of ' O Cons ❑ Demo ❑DPW O Elec ❑Energy Report
Board of ,
x r eats Health ' S Commission Affidavit Card Sent Cut Off 'Follow up
A Pp -
F
Planning t ❑Sewer Card ❑'Water Card ❑ Zoning ❑ Other r
❑ Fire , ^ ❑Gas
Chief xr Cut Off Board Cut OfF ;Cut 01f z
R , *REQUIRES INSPECTOR'S,R:EUIE1111.BEFORE THE ISSUANCE OF.A PERMIT ' ..:.." M ;
"
�.:DEPARTMENTALAPPROVAL
ZoDate: APR 30 2010
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: ' Date:
Other. Signature: Date:
,Brief description of work being performed:
,q C /
1.1 Property Address:'96/ 12caney,.l ;o�z aiz
Lot Area (sf.) 0 Frontage 'So/
Reouired Provided
Front Yard
Side Yard
hear Yard
1.2 Assessors Majp & Lot Number.
cJ Map Lot
dl-
1
1.3 Historical District ❑ Yes ❑ No
Haspplication been submitted to the Historic Commission?
Yes ❑ No Date:
1.4 Water Supply (MGL c40 s54): .5 Sewage Disposal System:
❑ Municipal 'Private Well ❑ Municipal J0 On Site Disposal System
CONSTRUCTIONEl
ENERGY _. :O
f RESIDENTIAL
- SECTION 2=:PROPERTY OWNERSHIP
UTHORIZED AGENT
l
2.1 Owner Record:
S� 9
4%si►'7
�4/ %�u/nays o� 'i1-✓l G3G�Z��'I
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)_
Contact Address Phone Number
` :SECTIONS` CONSTRUCTION
SERVICES,
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor: License Number:
Address: Expiration Date:
Signature: Telephone:
%4
3.2 Registered Home Improvement Contractor. Not Applicable ❑
®
Are you a Home Improvement Contractor subject to (780 CMR.1 I O.R6)? ❑ Yes ❑ No
If No, go to the next section!
Are you claming exemption from the requirements? ❑ Yes ❑ No
If Yes, submit the required affidavit!
Company Name: Registration Number (if none, state "none'):
Address: Z
"Signature: Te one: 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
1� I am a Homeowner performing all the work myself.
Owners Name (print): v �t
Signature: C
By signing the above0he homeowner acknowledviC that there will be no eligibility to the Guaranty Fund
r
Date:
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
5108.3.5 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:
J
Signature: - 4 --1�6�
Your signature carries certain responsibilities, including but not nece&tanly limited to, general liability I
SECTION 4 -`WORKER'S COMPENSAnON INSURANCE'AFFIDAVIT:(MGL c'.152 § 25)
Worker's 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 :S ='DESCRIPTION OF:PROPOSED;WORK'`ChecKall a - licabie
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. PORoofing/Siding ❑ Other
(Energy report required) _ (Shed/Garage) (Specify below)
❑ Addition 1W Replacement window/door ❑ Demolition
(Energy report required) No. of windows / M 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
❑ 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
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water. Gas Electric el Oil Other
Description of proposed work: �r J C51 ;
c,-.' / c
ECTION 6 'ESTIMATEDCONSTRUCTION'COST:1 n
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5 Total (1+2+3+4)
$00 0— ao
1 .
s ,. SECTION 7A OWNER AUTHORIZATION -
,.: ,;�.. -~ _ . (tq be completed when-;owner's-agert or contractor applies for building'pennit) ' �- __.: ;:: _.... :. ._ ;`
lease Print)
I, �[1►��l+r�t/'i � , as Owner of the subject property hereby authorize ��i L �+�'i'S
to act on my behalf, in all matters relative to work authorized by this building permit application.
I/ —/e—/ O
Pnature of Owner _ n Date
` _ �.S TION 7.B::`OWNER/AUThIORIZEDAGENTDECLARATION _
as Owner/Auth 'zed Agentreb declare that the statements and information
Y
on the foregoing application are true and accurate, to the best of my know a belief.
Signed under the pains and penalties of perjury.
—2-0''f'-0
ignature of ner/Aut orized nt p