BP-14780RESIDENTIAL 2000
❑ FOUNDA 2'ION ONLY,
$25.00 APPLICATION FEE IS NON-REFUNDABLE do NON -TRANSFERABLE
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O. Box 79399
Dartmouth, MA 02747 20, _ .
508-999-0720 FAX 508-999-0738
APPLICATIOrrO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Zoning Review: Signature: Date:
Energy Report: Signature: Dalt`e
Fire Chief: Signature: Q. Date:
Board of Health: Signature: // Date: _
Conservation Commission: Signature: Date:
Other: Signature: Date:
Description of work being performed:
NUMBER OF PLANS SUBMITTED: I
1.1 Property Address: 59-7 bArWQZ 5 boy
Nearest Cross Street:
Subdivision Name:
Total Land Area Sq. Ft.:
1.4 Water Supply (MGL c 40 § 54):
❑ Municipal 91frivate Well
SITE PLAN SUBMITTED: ❑ yes ❑ no
1.2 Assessors Plat & Lot Number:
Plat 1 _�j Lot '
1.3 Historical District ❑ yes N no
Has application been submitted to the Historic Commission?
❑ yes 14 no Date:
1.5 Sewage Disposal System: /
❑ Municipal CZ On Site Disposal System
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Rev. January 13. 2000
RESIT?ENTIAL 2000
_.
»> SECTiDNZ. PI2f7PE1t)€S O4YiFRSH1lxIALlf3fit}itED.G>r�tT
.....:::.....:::...... .
2.1 Owner of Record: P-6 e=F, A t 4b ��� � � �� �� r,,
12
S- ta�Tzv
Name (print) �bUTContact Address o'Y Phone Number
2.2 Aut W - 1(1'7
- ,��-- S l
Name (print) Contact Address Phone Number
SEC 1 IQ�i Q�Si IiITCTi u SEIi`EGES
3.1 Licensed Construction Supervisor: C HOC K (� (J t >'l_ Not Applicable ❑
Licensed Construction Supervisor Gt—k_Y_J!z� Q ISM License Number d `7 p D,3q
Address �� C ( I E W---5TTC)fC Mjcl Expiration Date
Signature Telephone 5 ; 63L_q54 o / 3 a04,
3.2 Registered Home Improvement Contractor: Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? L�'yes ❑ no
If no, go to the next section!
Are you claiming exemption from the requirement? ❑ yes ❑ no
If yes, submit the
required affidavit!
Company Name--Kf
V Registration Number (if none, state "none")
Address 3 (mot ( -T 7C N L.:� i's--)
Signature Telephone Sod - ,3�- ySt ' Expiration Date
1.3 For Residential Remodel Work Only
9
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
Owt.ers 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 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
❑ new construction* Vddition
(energy �r report re
quired) uired)
(energy re
port ort required) ed)
❑ deck ❑ pool ❑ accessory bldg.
(shed/garage)
* If new construction, please complete the following:
Single Family: no. of bedrooms
❑ alteration ❑ repairs ❑ chimney/ ❑ woodstove
fireplace
❑ replacement window/door
no. of windows . doors
no. of baths
Two Family: no. of bedrooms unit I 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:
❑ other ❑ demolition
(specify below): (specify below):
Item I Estimated Cost ($) to be completed by permit applicant I
5. Total = (I + 2 + 3 + 4) I -Estimated Total $ fir' y .C)
(please print
I, tfkt a " � � � , as Owner of the subject property hereby authorize 6H
to act on my behalf, ' all matters re tive to work authorized by this building permit application.
311➢/ae
Signature of O r Dates
Signature of OwnerXt horized Agent
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