BP-28374COMMERCIAL 2002 COIN•IIIERCIAL �2002--
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON-TRANSFERA13LE '7r�
J
SECTION - 12 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (S) to nearest dollar. To be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = (1 - 2 + 3 + 4)
Estimated Total Cost Including Labor: S
SECTION 13A - OWNER AUTHORIZATION to be com leted when owner's went or conactoraDnlies for building er
(please nt) /�
I, I bpi 1LQ.1/ L i"6 as Owner of the subject property hereby authorize
to act on my behalf, in all matt relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 13B - OWNER/AUTHORIZED AGENT DECLARATION
1, 1 i11/J YJ r lu as ONvner/Authorized Agent hereby declare that the statements and information
on the foregoing applicatic4i are true and accurate, to the best of my knowledge and belief.
Signed under the pains and peri lti perjury.
Signature of Owner/Agent Date
SECTION 14- INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed: 5. DENIED (see project review worksheet):
2. 30 days to review period expires; . Date-
3. OK to issue date: 6. HO,�/D reason: e7 �� �
13 153 G 4rl cr- /�t�,;,ti
4. OK to issue subject to requested submittals (see project att e:
review Nvorksheet): Date: 7. HOLD subject to Zoning Board of Appeals action:
8. Comments:
9. Inspector's Signature: Date:
SECTION 15 - APPLICANT NOTIFICATION
Applicant informed of above Date: Time: Clerk:
Comments:
SECTION 16 - FEE/PERNIIT NOTES
Total Permit Fee:
Less Application Fee: S 25.00
Remaining Balance:
Gross Area - New Construction
Gross Area - Alteration
Permit Issued To:
i
DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT
" 400 Slocum Road, P.O. Box 79399
Dartmouth, MA 02747
508-910-1820 FAX 508-910-1838
.APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A COMMERCIAL BUILDING (includes 3 or more family dwellings)
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY:
BUILDING PERMIT NUMBER:
DATE SENT FOR REVIEW:
DATE ISSUED:
OK TO ISSUE - SIGNATURE: DATE:
Building Commissioner/Inspector of Buildings
Zoning District: Proposed Use: Zone: ❑ C ❑ B ❑ A ❑ V Aquifer Zone
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑ Board of ❑ Board of ❑ Con. Y ❑ Demo ❑ DPW ❑ Elec. ❑ Energy Report
Appeals Health �C-oYn- T Affidavit Card Sent Cut Off Follow-up*
❑ Fire 6a " OPtanning ❑ Sewer Card ❑ Water Card ❑ Water Division ❑ Zoning ❑ Other
Chief IrP ff Board* / Cut Off / Cut Off Cross Connection Review*
REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE qF,A-PEItNrIT
DEPARTMENTAL APPROVAL
Zoning Review: Signature: Date:
Enemy Report: Signature: Date:
Fire Chief: Signature: _ .e, Date:
Board of Health: Signature: ,ww,A, j,� - Date:
Conservation Commission: Signature: al Date:
Other: Signature: Date:
Description of Work Beim- Perforated:
SECTION 1 - SITE INFORMATION
1 NUMBER OF PLANS SUBMITTED:
1.2 ITE PLAN SUBMITTED: ❑ yes ❑ no
1.3 Property Address:
.4 Assessors Plat & Lot Number:
Nearest Cross Street:
Bus. Name: Phone#
Plat Lot
Total Land area Sq. Ft.:
1.5 Water Supply (*NiGL c 40 § 54):
1.6 Sewage Disposal System:
unicipal ❑'Private Well
❑ Municipal 3,on Site Disposal System
1 SECTION 2 - PROPERTY OWNERSHIP / AUTHORIZED AGENT
2.1 Owner of Record:
Name (print
Contact Address Telephone
2.2 Authorized Agent-.
Name (print)
Contact Address Telephone
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rev. January 19, 2001
COMMERCIAL
2002
COMMERCIAL
2002
SECTION 3 - CONSTRUCTION SERVICES
,.1 Licensed Construction Supervisor:
Not Applicable ❑
Name of Construction Supervisor
License Number
Address
Expiration Date
Signature Telephone
SECTION, 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT MGLe 152 § 52
%Yorkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit
«vill result in the denial of the issuance of the building permit (MGL 152 Section 25A) Signed Affidavit Attached: ❑ yes ❑ no
SECTION 5 - DESCRIPTION OF PROPOSED WORK check all applicable)
❑ new construction ❑ addition ❑ alteration ❑ repairs ❑ accessory bldg. (shed/garage)
• other (specify Sec. 6): ❑ demolition Zign ❑ replacement window/door no. of windows doors
SECTION 6 - PROPOSED PROJECT/USE - INCLUDING THREE FA\iILY OR MORE AND EXEXIPT USES
The following descriptions are based on the ,Iassachusetts State Building 6th Edition, Code Article 3, as noted.- See the Code
❑ Assembly - restaurant, lounge, theater, school, etc. (see Code Section 302.0)
Describe:
❑ Business - office, assembly With less than 50 occupants - indicate Medical or other professional (see Code Section 303.00)
❑ Education - structure for training including child day care for those over 2 years 9 months (see Code Section 304.0)
❑ Factory / Industrial (see Code Section 305:0)
❑ High Hazard - (see Code Section 306.0)
❑ Institutional - hospital, nursing home, infant day care (see Code Section 307.0)
❑ Mercantile - retail stores (see Code Section 308.0)
❑ Residential - three or more family, hotel (see Code Section 309.0)
Storage - includes garage (see Code Section 309.0) e��
Utility & Miscellaneous Structures - includes tents and agericulttpral structurl6s (soe Code Section 311.0)
New Tenant - for any of the above, please indicate (see Code Sectiorf 119.Q '?nd'Zoning By -Law Section 35)
❑ Tent or Trailer - temporary .:
purpose?
❑ Other:
Describe the proposal briefly, INCLUDE number of dwelling units and bedddnil or occupant load as applicable, also existing
condition if extra space is needed, attach an additional sheet):_—�—;,,
SECTION - 7 TYPE OF 9GKSTRUCTION OR WORT: TO BE PERFORM D
❑ New Construction and/or Addition (total gross cubic feet proposed) - indicate
If the project is an addition to existing structure - total Gross square feet of existing:
;iteration of existing, no increase in gross square feet. A separate Refuse Disposal Declaration is required.
','.'ill this be subject to
project J CONSTRUCTION CONTROL (over 35,000 cu. ft.) ❑yes ❑ no
If yes see Code Section 116.0. Designer to submit Code Synopsis in addition to original plans.
Will this project require Peer Review (over 400,000 cu. ft.) ❑ yes ❑ no (see 110.1 Code & Appendix I)
APPLICANT TO PROVIDE PEER REVIEW AT THEIR EXPENSE. SEE 780 CDIR.
❑ Demolition* - describe structure:
\loving* - (provide copy of DPW moving license)
* Type of structure: from where (plat/lot or address):
to where (plat/lot or address): number of dwelling units:
number of bedrooms per dwelling omit:
❑
Replacement doors and windows - (for existing only) (only where doors and windows exist and will not be enlarged) EGRESS
dimensions must be maintained. Enlarged or new windows in an existing dwelling will be considered as an alteration, otherwise will
be included in new construction. (see Code Section 3603.21 for residential and Article 10 for commercial).
❑
Temporary structure - includes, when allowed, trailers, tents and the like and only for limited periods of time. Describe:
SECTION - 8 MECHANICAL& PRIMARY FUEL
❑
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
SECTION - 9 SPRINKLERS AND/OR FIRE PROTECTION
❑
Required: plans provided plans not provided, why?
❑
Not required, not to be installed, why?
SECTION - 10 REQUIRED OFF-STREET PARKING for Zonint, and Architectural Access
❑
Parking plan submitted to: Building Dept. Planning Board date submitted
Number of spaces - indoors outside total provided
Handicap spaces - required yes no if yes, how many as a part of the total required number
Is Route 6 (State Road) entrance permit required? yes no if yes, has it been issued? yes no
Submit copy of application and/or permit as soon as available.
SECTION - 11 IDENTIFICATION
11.1 Architect/Engineer - for overall design
Company Name:
Address:
Phone #:
Certified by State of Massachusetts as:
Certification Number:
Note: Signatures and seals on all plans, affidavits, c& other documents SHALL BE originals and not reproductions.
11.2 Architect/Engineer - project supervision and reports
Company Name:
Address:
Phone #:
Certified by State of Massachusetts as:
Certification Number:
Note: Signatures and seals on all plans. affidavits, c& other documents SHALL BE originals and not reproductions.
11.3 General Contractor
Company Name:
Address:
Phone #:
Construction Supervisors License Number
Note: Signatures and seals on all plans, affidavits, c& other documents SHALL BE originals and not reproductions,
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