BP-18877H151DENTIAL_ _
� 2001
SECTION 8 - 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): Date:
5. DENIED (see project review worksheet): Date:
6. HOLD reason: Date:
7. HOLD subject to Zoning Board of Appeals action: Date:
8. Comments:
9. Inspector's Signature:
Date•
( SECTION 9 - APPLICANT NOTIFICATION
Applicant informed of above Date: Time: Clerk:
Comments:
SECTION 10- OFFICE\INSPECTOR'S NOTES
Total Permit Fee: 8
Less Application Fee: S 25.00 Remaining Balance: S
TOTAL FEE: Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft._ �q-
Permit Issued To- ,GLi� /-s.�._�'�- ev
ell
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SECTION 11 - ADDITIONAL COMMENTS/SKETCHES
Pace -4
BUILDING P ��
NUMBER:=—�-
DATE ISSUED:
DATE_FEB 1 J 2001
,eyw►amg Lommissioner/Inspector of Buildings
Zoning District: Proposed W �'� Zone: 0'C ❑ B ❑ A ❑ V Outside Flood Zone ❑ Aquifer Zone —
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
❑ Board of ❑ Board of ❑Con. Com. ❑ Demo ❑ DPW ElElec. ❑Energy Report
Appeals Health Affidavit Card Sent: Cut Off Follow-up*
❑ Fire ❑ Gas ❑ Planning Board* ❑ Sewer Card ❑ Water Card
Chief Cut Off / Cut Off / Cut Off
* REQUIRES INSPECTOR'S,REVIEW BEFOR& TIRE I5SUANQE OF A
2001
Zoning Review: Signature:
Energy Report: Sitnature,
re:
Fire Chief: Si
Board of Health: Si atur
Conservation Commission: Signature:
Other: Signature:
Description of work being performed:
NUMBER OF PLANS SUBMITTED:
A
RESIDENTIAL
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NniN-REFUNDABLE & NON -TRANSFERABLE
DARTMOUTH BUILDING DEPARTMENT DATE RECEIVED
400 Slocum Road, P.O. Box 79399
Dartmouth, MA 02747
508-999-0720 FAX 508-999-0738
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY•
DATE SENT FOR REVIEW:
OK TO ISSUE - SIGNATURE:
/v1
❑ Zoning ❑ Other
Review*
Date:
Date:
,Date:
Date:
Date:
- SITE INFORMATION
SITE PLAN SUBMITTED: ❑ yes ❑ no
h 1.2 Assessors Pl& at Lot Number:
1.1 Property Address � �1i) %-tl AICCI ��
.Plat Lot /�_-
Nearest Cross Street:
Subdivision Name:
Total Land Area Sq. Ft.:
1.4 Water Supply (MGL c 40 § 54):
❑ MunicipalwPrivate Well
1.3 Historical District ❑ yes ❑ no
Has application been submitted to the Historic Commission?
❑ yes ❑ no Date:
1.5 Sewage Disposal System:
❑ Municipal ,Pi~1 On Site Disposal System
Rec. January 19. 2001
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2001
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SECTION 2 - PROPERTY OWNEr.SHIP AUTHORIZED AGENT
2.1 Owner of Record:
l- eiW/7k/
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
tY
Name (print)
Contact Address Phone Number
SECTION 3 - CONSTRUCTION VT E
3.1 Licensed Construction Supervisor: A3 _ LA__1 61117-11V 1;(
Not Applicable ❑
Licensed Construction Supervisor G oo
License Number t
Address a��, ) } t t
Expiration Date
F
J!�:
Si naturer �e/ �� Tele hone i-''
g '���
3.2 Registered Home Improvement Contractor:
Not A plicab e ❑
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.4 no
If yes, submit the
required affidavit!
Company Name ,,- ` �' f" `�
Registration Number (if none, state "none")
% C�
Address 1 Cr��� , y� t _%
G
Signature �''� Telephone
Expiration Date ' 77,z;
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, MA 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 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 dwelline, 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
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 Aalteration ❑ repairs ❑ chimney/ ❑ woodstove
(energy report required) (energy report required) fireplace
❑ deck ❑ pool ❑ accessory bldg. 1*placement window/door ❑ other ❑ demolition
(shed/garage) no. of windows doors W. (specify below): (specify below):
* 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 (specify):
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Brief Description of Proposed Work:
/% r7 / l
LI
-'-SECTION - 6 ESTIMATED CONSTRUCTION COSTS ,
Item
Estimated Cost ($) to be completed by permit applicant
1. Buildin
2. Electrical
3. Plumbin
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4)
*Estimated Total $ V5r o-1-0 , m
SECTION 7A - OWNER AUTHORIZATION
(to be completed when owner's agenf or contractor applies for building permit)
(p)l�,= print)
1,.,,..� , , as Owner of the subject property hereby authorize 1 -. C C,
tQ act on my beh , i afters relative to work authorized by this building permit application.
. n re c ;O_ er Date
SECTION B- OWNER/AUTHORIZED AGENT DECLARATION
Z J\ V\ : A v Y,r• r , as Owner/Authorized Agent hereby declare that the statements and information
on the foregoin application are true and accurate, to the best of my knowledge and belief.
Signed under the pains(andgzenalties of perjury.
Si % of OwnedAuthorized Agent Date -
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