BP-457938 - INSPECTOR'S`REVI
❑ SPECIAL PERMIT (Per 780 CMR 111.13)
$25.00 APPLICATION FEE IS NON BE-FITNDAIILE & NON-TIIANSFEIIAIILE
1. Date plan reviewed:
2. DENIED (see project review worksheet):
3. HOLD
Reason:
4. HOLD subject to Zoning Board of Appeals action:
Comments:
Inspector's Signature:
Applicant informed of
Comments:
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Date:
Date:
Date:
Date: E4 b46
Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: $�
Other $ Amount $
TOTAL FEE: Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
DATE RECEIVED
UT° DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O. Box 79399
o C7;
Dartmouth, MA 02747
.� . 1664�;fy�f Phone: 508-910-1820 Fax: 508-910-1838
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
DEPARTMENTAL APPROVAL
Zoning Review:
Signature: 6 zlh1 Q ��„--��
Date:
Energy Report:
Signature:
Date:
Fire Chief:
Signature:
Date:
Board of Health:
Signature: (J l� '�%�-�# �c%'ZC_
Date: •�
Conservation Commission:
Signature:
Date:
Other:
Signature:
Date: `
Brief description of work being performed:
SECTION 1,r`SITE INFORMATION""
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1.1 Property Address:
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1.2 Assessors Map &Lot Number:
Nearest Cross Street:
Map Lot-
Subdivision Name:
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1.3 Historical District ❑ Yes ❑ No
Total Land Area Sq. Feet:
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
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1.4 Water Supply(
0 s54):
1.5 Sewage Disposal m:
❑ Municipal
Private Well
El Municipal Disposal System
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❑ CONSTRUCTION PLANS ❑SITE PLAN ❑ENERGY REPORT
RESIDENTIAL
SECTION 2 -`PROPERTY OWNERSHIP/AUTHORIZED
AGENT
2.1 Owner Record:
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Name (print)
Contact Address Phone m r
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2.2 Authorized Ag t:
Name (print)
Contact Address Phone Number
SECTION 3 - CONSTRUCTION; SERVICES
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 claming exemption from the requirements? ❑ Yes ❑ No
If Yes, submit the required affidavit!
Company Name:
Registration Number (if none, state "none"):
Address:
Signature: Telephone:
Expiration Date:
3.3 or 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
X "` am a Homeowner performing all the work myself.
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Owners Name (print): 1
-
Signature: v U
BI sig/n ng the above, the omeowner acknowledges that there will be no eligibility to the Guaranty Fund
Date: r�V' z
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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.
you are applying and ,this sectio�Sln below:
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Signature: /
Your signattire carries certain
esponsibilities, including but not necessarily limited to, general liability
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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)
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 5 =`DESCRIPTION OF PROPOSED WORK (Check all applicable)
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction' ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage) (Specify below)
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❑ Addition ❑ Replacement window/door ❑ Demolition (�
(Energy report required) No. of windows _ Doors _ (Specify below) ► 5f/Yyt
*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 Fuel Oil Other
Description of proposed work: . Pj
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SECTION 6 -'ESTIMATED CONSTRUCTION COST : '.
t Item
Estimated Cost ($) to be completed by permit applicant
1. Building �f r
2. Electrical
3. Plumbing `,,t '
4. Mechanical (HVAC) <91
5 Total =0+2+3+4)
SECTION 7A - OWNER AUTHORIZATION
(to be completed when owner's'agent or contractor applies for building permit)
(Please Print). � '7,
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, _ 1 r�l d4yj. as Owner of the subject property hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
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Signature of Owner Date
SECTION 7B - OWNERIAUTHORIZED AGENT DECLARATION
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1�_ as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing application are t 'lue and accurate, to the best of my knowledge and belief.
Signed unde, ^the pains and Denalties of perjury.
ignature'of Owner/Authorized Agent Date
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