BP-25327RESIDENTIAL
2001
SECTION 8r INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed:
2. 30 days to review period expires:
3. OK to issue date:
4. OK to issue subject to requested submittals(see project review worksheet):
5. DENIED (see project review worksheet):
6. HOLD reason:
Date:
Date:
Date:
7. HOLD subject to Zoning Board of Appeals action:
8. Comments:
Date:
9. Inspector's Signature: 1 _
Date:
SUCTION 9 - APPLIC N TIFICATION
Applicant informe4 of idbove ate: l e. Timer �
Comments:
Cl
SECTION 10- O ICE\INSPECTOR'S NOTES
Total Permit Fee: $
_7
Less Application Fee: $ 25.00
Remaining Balance: $
TOTAL FEE: Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued To* 3o X --p-),(.
v�
6
SECTION 11-ADDITIONAL COMMENTS/SKETCHES
RESIDENTIAL 20
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE tr T Z-
``�`;UTh"''` DARTMOUTH BUILDING DEPARTMENT,DATE RECEIVED
400 Slocum Road, P.O. Box 79399
Dartmouth, MA 0274715
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY. j BUILDING PERMIT +
DATE SENT FOR REVIEW: (a-QZ =- NUMBER 5;
,.. ...<<< �DATEISSUED:�
—.
OK TO ISSUE - SIGNATURE:
..., DATE
- _ nL':Id!-� lyrene nnar/F c�s nr of R.e lAen c r_ _
Zoning District: &roposed Use. Zone: L�f'C ❑ B ❑ A Q" Outside Flood Zone ❑ Aquifer Zone
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED
❑ Board of ❑Board of ❑Con Com ❑Demo ❑DPW t7 Elec ` ❑Energy Report
z
Appeals . - Health ? Affidavit °.Card Sent. _ Cut Off Follow-up*
❑ Fire ❑ Gas ❑ Planning Board* ❑ Sewer Card
-❑ Water Card g ". ❑Zoning ❑Other
Chief 'Cut Off / Cut Off `'L Cut Off Review*
* REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
. .. _ '; ` _=DEPARTMENTAL APPROVAL _ _
Zoning Review: Signature: Date:
Energy Report: Signature: Date:
Fire Chief Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other: Signature: Date:
Description: of work being performed:
SECTION 1- SITE INFORMATION
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes ❑ no
c 1.2 Assessors Plat & Lot Number:
1.1 Property Address: Plate Lot
Nearest Cross Street:
Subdivision Name:
Total Land Area Sq. Ft.:
1.4 Water Supply (MGL c 40 § 54):
❑ Municipal❑ Private Well
1.3 Historical District ❑ yes ❑ no
Has application been submitted to the Historic Commission?
❑ yes ❑ no Date:
1.5 Sewage Disposal System:
❑ Municipal ❑ On Site Disposal System
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RESIDENTIAL 2001
SE T12 PROPERTY 0WNER HIP AUTHORIZED AGENT
2.1 Owner of Record:
Name (print) ) Contact Address Phone Number
)jot A LO
Name (print)
Contact Address Phone Number
�J- l\J1rtV ■wig crtvr�.�
3.1 Licensed Construction Supervisor:
- -
Not Applicable ❑
Licensed Construction Supervisor
License Number
Address
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ 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
Registration Number (if none, state "none")
Address
Signature Telephone
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, AAA 02108, (617) 727-8598
Owners Name (print)
Signature---,,-
by signing the above, the home owner acknowledges that there will be no eligibilty 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 of
buildings or structures, unless he or she is licensed in accordance with the rules and regulations by BBRS
promulgated the 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
RESIDENTIAL
2001
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15)
SECTION 4 -WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL C 152 § 25)
Workers 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 5 - DESCRIPTION OF PROPOSED WORK (check all applicable)
❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ ❑ woodstove
(energy report required) (energy report required) fireplace
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door other ❑ demolition
(shed/garage) no. of windows doors (specify below): (specify below):
* If new construction, please complete the following:
Single Family: no. of bedrooms ro. 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 (specify):
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Brief Description of Proposed Work: 3 0Y -Z --F_C_
aCe ---I
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost ($) to be completed by permit applicant
1. Buildiniz
2. Electrical
3. Plumbing
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4)
* Estimated Total $
SECTION 7A - OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(please
print)
1, I , as Owner of the subject property hereby authorize -C
to act on my behalf, in all matter IlItive to work authorized by this building permit application.
yl& I'Ll. Z
-
Signature of Owner Date
SECTION 7B - OWNER/AUTHORIZED AGENT DECLARATION
1,zkA, LCA , as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing app ' ation are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
1AA-14 — �� att-y- - 77
---
Signature of Owner/Mithorized Agent Date
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