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1600 TO THE APPLIGINT/REFERRAL AND APPROVAL ,
Date of Apk'cation submission
Plat Lo t[,treet
Zone
Owner J
elan I
Owner mail address
M
Owner phone #
=*=*i*iii====i#isiis####*###iissiis#iiisiiii#=ii==i#i#i!#fi#iii!#!ti#iii#iiilii!=i#ii#lisis!!!ii#i##iilif OTHER INVOLVED AGENCIES _The following agencies require separate jurisdictional
Proposed project. CONTACr 77 EM FOR ��nDvn �.l,�,no� approval for your
® TAX COLLECTOR = Approved V HOLD By
❑ Board of Appeals Approved By
❑ Conservation Commission L. Approved By
O D.P.W. Water Approved By 0 D.P.W.
❑ D.P.W. Cross Connection a Approved By
❑ Treasurer (Bond) ❑ Approved By
❑ D.P.W. Engineering :_ Approved By
7 Soard of Health (well)
_ Approved By
TOWN. OY DARTMOUTH" BUILDING DEPARTZVIENT
TELEPHONE 508-999-0720
IFAX> 508499-0738
APPLICATION FOR ZONING AND BUILDING PERMIT
Instroetions
The applicant shall complete this application to the best of their ability prior to submission, leaving no item ®answered. The
Department staff will be available during regular business hours to assist as necessary. N/A should be inserted for those sections
which do not apply. A properly completed application will help avoid unnecessary delays, M06C }i6 fee i• not i IF v .
Date
(for once use only) 171 Fn TION ONLY
Date Total Cost Received By 4 Date Reed
Date
Less Application Fee S xx
Total Permit Fee $ Permit # fJ Issued Date
Date
Date 100 LOCATION OF PROJECT TOTAL LAND AREA SQUARE FEET S
Date
CURRENT ACCESSORS' PLAT LOT ZONING DISTRICT
Date
- - —' Date
❑ Board of Health (septic) = proved By
Date
❑ Board of Health (food s ice) = Approved By
Date
❑ Planning Board (p g) _ Approved By
Date
® FIRE DISTRICT (I - II - III) _ Approved By
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BUILDING DEPARTMENT APPROVAL:
❑ ZONING
❑ BUILDING INSPECTORBUILDING COMMISSIONER
❑ CONTROL CONSTRUCTION AFFIDAVIT
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PROJECT SUMMARY:
new construction/ alteration/demo
Wter;add interior walls] [add rooms) [add footprint]
sewage disposal - publiciprivate
[pool] [garage; shed/deck] [game court] [food service
Describe
a�Q16� C C
water supply - public/private well
To the various departments:
U
This notice has been forwarded to you for your information and any appropriate action. Should you have any
questions please advise. If any reason to withhold the reques d permit is found, please advise. Your assistance and
cooperation is appreciated.
The Building Department - Date sent for review 3 L)6
By
OTHER ZONING OVI
NUMBER & STREET
NEAREST CROSS STREET
SUBDIVISION NAME & LOT #
or BUSINESS NAME
PREVIOUS TENANT / OWNER
200 RESIDENTIAL - PROPOSED PROJECT - one & two family residence only
- THIS SECTION NOT APPLICABLE
— Single family - number bedrooms number baths
= Two family - number bedrooms unit 1 number baths unit 1
number bedrooms unit 2 number baths unit 2
Accessory apartment Total gross sq. ft.
_ Accessory structure:
= Garage - detached - attached to dwelling, dimensions L W
Carport.- detached - attached to dwelling, dimensions L W
= Shed - dimensions L W
Deck - dimensions L W
Gazebo - dimensions L W
_ Swimming pool above ground in -ground Size
Chimney - number of flues
_ Woodstove - used (will require inspection prior to installation), new (provide manufacturers
The following section for official use only.
instructions). Location(s) (list)
INSPECTORS' REVIEW
Fireplace(s) - (includes flue) List location(s)
Date plan reviewed
= Game Court - describe (include overall dimensions)
30 days to review period expires
Tent, Trailer (Mobile Home) or Other - describe
= OK to issue date
300 COMIIMERCIAL - PROPOSED PROJECT/USE - INCLUDING THREE FAMILY OR MORE AND EXEMPT USES
OK to issue subject to requested submittals (see project review worksheet) date
= THIS SECTION NOT APPLICABLE
= DENIED see project review worksheet date
(The following descriptions are based on the Massachusetts State Building Code Article 3, AS NOTED) (See the
� HOLD reason date
Code)
= Assembly - restaurant, lounge, theater, school, etc. (see Code Section 302.0) Describe
= HOLD Subject to Zoning Board of Appeals action
Comments
- Business - office, assembly with less than 50 occupants - indicate Medical or other professional (see Code
Inspectors signature Date 1998
Section 303.0)
7
- Educational - structure for training including child day care for those 2
Applicant informed of above - Date time staff (fax, phone, in person)
over years 9 months (see Code Section
304.0)
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= Factors / Industrial - (see Code Section 305.0)
= Over six months since approved for issue - DEEMED abandoned!
Advise applicant. Hold 90 days for return then dispose if not picked up.
= High Hazard - (see Code Section 306.0)
= Institutional - hospital, nursing home, infant day care (see Code Section 307.0)
Inspector Date
Mercantile - retail stores (see Code 308.0)
= Advised applicant Date Time staff (by phone, fax or in person)
= Residential - three or more family, hotel (see Code Section 309.0)
OFFICEVNSPECTORS NOTES
Storage - includes garages (see Code Section 309.0)
00
TOTAL FEE
- Utility & Miscellaneous Structures - includes tents and agricultural structures (see Code Section 311.0)
= New tenant for any of the above, indicate above (see Code Section 119.0 and Zoning By-law section 35)
_ Tent or Trailer - temporary purpose?
Other
Describe tine proposal briefly, INCLUDE -umber of dwelling units and bedrooms or occupant load as applicable,
also eusting condition
40 TYPE OF CONSTRUCTION OR WORK TO BE PERFORMED
= New Construction and/or Addition - total gross square feet
(For commercial only total gross cubic feet) - indicate
It will be considered new construction if there an increase in square footage in addition to anv
alteration(s).
If project is an addition to existing structure - Total gross square feet of existing
= FOR COMMERCIAL ONLY
Will this project be subject to CONSTRUCTION CONTROL (over 35,000 cu.ft.) Yes No. (If yes
see Code section 127.0). Designer to submit Code Synopsis.
Will this project require Peer review (over 400,000 cu.ft.) Yes No (see Code Appendix 1)
APPLICANT TO PROVIDE
Gross area - new construction Total Sq. Ft.
alteration Total Sq. Ft.
Permit is issued to
Comments/notes on permit
_. .... r_
1300 OWNER SIGN - OFF
= Alteration of existing, no increase in gross square feet. A separate Refuse Disposal Declaration required.
I. the undersigned, am the owner of record or authorized lessee (provide documentation) and I have reviewed
the application herein submitted. I state that to the best of my knowledge and belief that the information provided in this
application is true -and correct and that the permit requested be issued.
Further I understand that the permit will expire in six months, from the date of issue, if no work is begun or
six months after the last inspection if work has begun and�that the permit may be extended for six months if no work is
written request. I understand that once the permit expires a new application may be required, includinanticipated if I request such an extension in writing. I understand that the permit may be extended only three times by
other requirements (inc ing Zon g fees and current
Name
4
ignature
/D.-
eabove signature is my voluntary act an is signed under the pains and penalties of perjury.
't
, f
te
Who is authoried to pickup the permit at the Building Department? r lease rinn f
Address Phone
1400 HOMEOWNER EXEMPTION - ONE & TWO FAMILY ONLY
FOR H0ME OWNERS 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 127.0, 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 accord2-ce with the rules and regulations promulgated by the BBRS entitled
Riles and Regulations for Licensing Construction Supervisors.
Exception: Any Home Owner performing work for which a Building Permit is required shall be exempt from
the provisions of this section; provides that if a Home Owner engages a person(s) for hire to do such work ,that such
Home Owner shall act as supervisor.
For the purposes of this section only, a "Home Owner" 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 dweilin,attached
or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in
two-year period shall not be considered a Home Owner.
If you are applying under this section sign below:
Signature
Your signature carries certain responsibilities, including but not necessarily limited togeneral
liability s*:sss
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any
licensed Construction Supervisor, whether or not thev have taken the permit are responsible for code comp2.15.2 of section 5)Hance. (see
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1500 COST
Cost of Improvement S
Items to be installed but not included in the above cost:
TOTAL
Electrical S
Plumbing
HVAC
Other
= Demolition - describe structure
Number of dwelling units Number of bedrooms A separate Refuse Disposal
Declaration requixsd.
Moving - (Provide copy of D.P.W. 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 unit
— Re-roormg - (for existing only, is included in new construction)
Number of square feet Number of layers already existing
Number of layers when complete
A separate disposal declaration REQUIRED
= 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 3401.10 for
residential and Articl- 8 h.: commercial)
Temporary shmcture - includes when allowed, trailers, tents and the like and only for limited periods of time.
Describe
500 CONSTRUCTION PLANS
— None submitted. Why?
= Submitted, usually three sets required. Four sets for food service uses. Number of sets submitted
600 SITE PLAN
/1"0' Not required, why?
Submitted When? = Previously, date With this application
700 UT L I71ES
Water supply - required _ yes _ no, public ? _ yes _ no, on site well? _yes _ no,
existing? _ yes _ no
If required and not existing have necessary permits been issued? _ no _ yes, date
(M.G.L. Chapter 40, section 54 provides that no building permit may be issued unless a water supply, when
required, is available. See Code 780 CMR section 114.1.2)
Sewage disposal - required _ yes _ no, public sewer _ yes _ no
private septic - on -site _ yes _ no. Submit copy of permit as soon as available.
800 MECnAMCAIS & PRIMARY FUEL
Architect/En&eer - project supervision and reports
= 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
900 SPRINIMM - FOR STRUCTURES OVER 7500 SQUARE FEET and certain multifamily residential
Required, --Plans provided, plans not provided, why?
Not required, not to be installed, Why?
1000 REQUIRED OFF-STREET PARMG - for ZONING &Architectural Access
= NOT APPLICABLE
= Parking Plan submitted To = Building Department L Planning Board Date submitted
Number of spaces - indoors outside total provided
Handicap spaces - required _ yes _no. If yes, how many as a pirt 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.
1100 IDENTIFICATION (print or type except as noted)
Current owner - name
address
phone #��
f �.L/ h%�
If corporation, of tcer in ch1arg%e
Architect/Engineer - for overall design
Company name
Address
Phone number
Certified by State of Massachusetts as
Certification number
NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals and not
reproductions.
Company name
Address
Phone number
Certified by State of Massachusetts as
Certification number
NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals and not
reproductions.
General Contractor (if Homeowner, state homeowner here then complete section 1300)
Compare
Address
Phone nt
Construction Supervisors license number
NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals and not
reproductions.
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1200 FOR RESIDENTIAL REMODEL WORK ONLY
Are you a Home Improvement Contractor subject to (780CMR - 6) ? Yes _ No _ If no go to next section!
Are you claiming exemption from the requirement? Yes _No _If yes, submit the required affidavit:
Rea,)del contractor name (please print)
Address
Registration number (it none state "none")
Phone number
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE
GUARANTEE 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