BP-56817SECTION 8 INSPECTOIRS_REVIEW/COMMENTS
[ Approval in Part (Per 780 CMR.5111.13)
S25.00 APP ATl10N FEE ]IS NON RE-FUNFARLE c& NON -TRANSFERABLE
_ �PAT&RECEIVED
ARTNiOUTH BUILDING DEPARTMENT ,
-�� y..
400 Slocum Road, P.O. Box 79399
i:z y Dartmouth, MA 02747 10: QL
Phone: 508-910-1820 Fax: 508-910-1838
www.town.dartmouth.ma.us
ecci tCATinN Tn MNSTRUCT_ REPAIR. RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Zoning Review: Signature: L-- Date: ✓��
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature. % Date:
n+k-- Cinnatl irw / Date:
- CONSTRUCTION
1.2 Assessors Map & Lot Number:
Map /� Lot /..I— -
1.3 Historical District ❑ Yes ❑ No
Has application beep
ubmitted to the Historic Commission?
❑ Yes M No Date:
..� vcvvavc vwNvaa. vy.� ��.
❑ Municipal On Site Disposal System
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SECTION 2 , :PKOP. ERTY°OWNERSHIP/ADTHORIZED:'AGENT.
=:
2.1 Owner Record: o&6 (�/Jm&x_
Name (print)
Contact Address Phone Number
2Vuthorized geni;�
f t= ter - r -t 461
` R9 dollIkS do�s� �' ��3 r �� /
-
Name (print).
Contact Address Phone Number
"SECTION 3 -:CONSTRUCTION
SERVICES
1 Licensed Construction Supervisor: -
Not Applicable ❑
Licensed Construction Supervisor:
License Number: 717
Address: & �— V ,
Expiration Date:CIN
Signature: ��b-vaGZ►t
/
3.2 Registered Home Improvement Contractor.
Not Applicable ❑ '
Are you a Home Improvement Contractor subject to (780 CMR.110.R6)? lies ❑ 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: 6.11Z C J
Registration Number (if none, state "none'):
Address: 19 P 17 CIO cog
as 6 A3
Signature: �iv1,�}g/tl Telephone j1G Q J wZ !/ %
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, MA 02108, 617-727-8598
❑ 1 am a Homeowner performing all the work myself.
Owners Name (print):
Signature:
By signing the above, the homeowner acknowledges that there will be no eligibility 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
5108.3.6 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.
If you are applying under this section sign below:
Signature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
C
:SECTION 4='1NORKER'S.COMPENSATION INSURANCE:`AFFIDAVIT(MGL c`:152
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
DESCRIPTIONOF:::PROPOSED;WORK(Check all.applicable)
❑ Deck ❑ Pool �epairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage) (Specify below)
❑ Addition ❑ Replacement window/door ❑ Demolition
(Energy report required) No. of windows _ Doors _ (Specify below)
*If new construction, please complete the following:
Single Family: No. of Bedrooms No. of Baths
Two am!ly: No of Bedrooms Unit 1 No. of Baths Unit 1
No of Bedrooms Unit 2 No. of Baths Unit 2
❑ Fdmace (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
ON IN3 Ck
Description of proposed work: .; iZe4 df( -- .
2 i
-. _ . t .. -<SECTION 6 ESTIMATED ;`.,CONSTRUCTION COST _ -
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
Q�r —
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = (1 + 2 + 3 + 4)
SECTION.7A OWNER AUTHORIZATION k.
_ r
.,,
(to be completed:when:owner's-agent o.r-contractor appl.ie"s for6uilding'permlt) = ..;. _
(Please 6in� _
.� , as Owner of the subject property hereby authorize • Y'/��� I � /VC-;4 l2ti/4-�
to act on W behalf, in all matters relative to work authorized by this building permit application.
Sign ture of Own r Date
- SECTION 7.B;'-`OWNER7AUTHORIZED.'AGENT DECLARATION
as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Eigned under the pains and penalties of perjury.
Signature of Owner/Authorized Agent Date