BP-80385\0 �-
dv
FILE Cf�F
-Z�,0
TOWN OF DARTMOUTH
RECORD PLAN
A Copy Of This Endorsed
Plait east Be Kept ®r. Site
® f � r��ilCti •:7
Date `f
GA ► t
2e.n 42-
YOUR DRAVIMIG MUST BE KEPT
AT THE BUILDING DURING THE
PROGRESS OF TI IIS WORK.
BUILDING DEPARTMENT
Town of Dartmouth
" � �-tt•'�L
L4 C. (A �Gn
0L),,s`L
Y8 ek(I►� L-(�«
c-
3�`i
_. ssi##ss#ssi#ssifissssfifiii#isiiiiif!lissiiiisii!ltiiitiisisiissississfsls:#i##ii:tsiiiss:lsiits:sssss::
i600 TO THE APPLICANT/REFERRA[, AND APPROVAL /
Date of Application submission
Plat 1 Lot �' Street
Owner '✓ j lk-�s, � A 4 �(
Owner mail address
k) -(—c
e7-4�m
r Zone
Owner phone
sixxsisf##sf#fi#fsx#i##!#f#ii#i#iis#fx#s#saiiisi#ssf#fssisisisssesssssissssssss=ssssiiisss##iisi#s##sssss
OTHER INVOLVED AGENCIES - The following agencies require separate jurisdictional permits or approval for your
proposed project. CONTACT THEM FOR REOUnm mgly)iS,SiONS-
s TAX COLLECTOR Approved HOLD By Date
❑ Board of Appeals = Approved By Date
Conservation Commission G Approved By � � Date -'
❑ D.P.W. Water Approved By _ ❑ D.P.W. Sewer = Approved By Date
❑ D.P.W. Cross Connection a Approved By
❑ Treasurer (Bond) ❑ Approved By
❑ D.P.W. Engineering Approved By
Date
Date
Date
7 Board of Health (well) :: Approved By Date —
❑ B and of Health (septic) ;=; Approved By Date
C+ Board of Health (food service) = Approved By _ Date
❑ Planning Board (parking) = Approved By Date
® FIRE DISTRICT (I - II - III) _ Approved By Date
sssss:ssssssssssssssssssssssssssssssssssssssssssssrsssssssssasasssssssssssssssssssssssssssssssssssssssss
BUILDING DEPARTMENT APPROVAL:
❑ ZONING
❑ BUILDING INSPECTORBUILDING COMMISSIONER
❑ CONTROL CONSTRUCTION Ar FIDAVIT
PROJECT SUMMARY.
new cons.Yuctioni alteration/demo
sewage disposal - public/private
[Alterradd interior walls] [add rooms) [add footprint]
[pool] [garage/shed/deck] [game court] [food service]
Describe
To the various departments:
water supply - publiciprivate well
#lfiff###iii#iiii#fi#i#fii #ii##i#!##i!###
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 requested permit is fou. d, please advise. Your assistance and
cooperation is appreciated. /
The Building Department - Date sent for review(0 C? By
4
TOWN OF DARTMOUTH .BUDLDING DEPARTMENT
TELEPHONE 508-999-0720 FAX> 508-999-0738
APPLICATION FOR ZONING AND BUILDING PERMIT
Ia4frmeSom .
The applicant shall complete this application to the best of their ability prior to submission, leaving no item nmamswered. 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. Nstts Filrog fee is mi -p ' '
(for office me only)
Total Cost $ Received By
Less Application Fee $i
Total Permit Fee �_-�'ermit #
100 LOCATION OF PROJECT TOTAL LAN
i
CURRENT ACCESSORS' PLAT/ LOT``^ —
OTHER ZONING OVERLAY DISTRICTS
y
S , if applicable
NUMBER & STREET 3 S-`7. 5. 1 T r) I -I L-
NEAREST CROSS STREET
SUBDIVISION NAME & LOT #
or BUSINESS NAME
PREVIOUS TENANT / OWNER
0. POUNDA .ON ONLY
Date Reed GI l U
L%ued Date
AREA SQUARE FEET
200 RESIDENTIAL - PROPOSED PROJECT - one & two family residence only
= THIS SECTION NOT APPLICABLE
DISTRICT . ?' —
= S--.gle 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 groun �-grouSize t 6 K 32
-- Chimney - number of flues
- Woodstove - used (will require inspection prior to installation), new (provide manufacturers
instructions). Location(s) (list) o h
The following section for official use only.
INSPECTORS' REVIEW
- Fireplace(s) - (includes flue) List location(s)
- Game Court - describe (include overall dimensions)
Tent, Trailer (Mobile Home) or Other - describe
300 COMMERCIAL - PROPOSED PROJEC 1USE - INCLUDING THREE FAMILY OR MORE AND EXEMPT USES
- THIS SECTION NOT APPLICABLE
(The following descriptions are based on the Massachusetts State Building Code Article 3, AS NOTED) (See the
Code)
- Assembly - restaurant, lounge, theater, school, etc. (see Code Section 302.0) Describe
- Business - office, assembly with less than 50 occupants - indicate Medical or other professional (see Code
Section 303.0)
- Educational - structure for training including child day care for those over 2 years 9 months (see Code Section
304.0)
- Factory / Industrial - (see Code Section 305.0)
- High Hazard - (see Code Section 306.0)
- Institutional - hospital, nursing home, infant day care (see Code Section 307.0)
- Mercantile - retail stores (see Code 308.0)
- Residential - three or more family, hotel (see Code Section 309.0)
- Storage - includes garages (see Code Section 309.0)
- 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
t
Describe the proposal briefly, INCLUDE - amber of dweiiing omits and bedrooms or occupant bad as applicable,
licab
aalsoezisting condition
1
400 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 ves
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 I)
APPLICANT TO PROVIDE
Date plan reviewed
30 days to review period expires
- OK to issue date
OK to issue subject to requested submittals (see project review worksheet) date
- DENIED see project review worksheet date
- HOLD reason
HOLD Subject to Zoning Board of Appeals action
Comments
Inspectors signature
- Applicant informed of aboV6 - Date
date
Date %// 7
staff (fax, phone, in person)
- Over six months since approved for issue - DEEMED abandoned!
Advise applicant. Hold 90 days for return then dispose if not picked up.
Inspector Date
- Advised applicant Date Time staff (by phone, fax or in person)
ii#ill#iii##i#iii#i##iii#iii#iiiiiiiill#till#ill#lliiii##!####!i!illilt#i########ill#i##iiiiilit##i#l##i
OFFICEUNSPECTORS NOTES (�
TOTAL FEE
Gross area - new construction Total Sq. Ft.
alteration Total Sq. Ft.
Permit is issued to
Comments/notes on permit J���'_�'" Q �/Y �� `�✓�
Aid—
-76;-"
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
anticipated if I request such an extension in writing. I understand that the permit may be extended only three times by
written request. I understand that once the permit expires a new application may be required, including fees and current
other requirements (including Zoning).
Name
The above signature is my voluntary act and is signed under the pains and penalties of perjury.
Date
Who is authorized to pickup the permit at the Building Department? (Please anina 1► %j L CLievAE
Ph
Address one
1400 HOMEOWNER EXEMPTION - ONE & TWO FAMILY ONLY
FOR HOME 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 accord2rce with the rules and regulations promulgated by the BBRS enti!'ed
Riles and Regulations for Licensing Cons"ction 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 ,jnly, 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 familv dwellin , 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 to, general liability
ss===ss=ssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssss:::sass*ssssssssssssssssssssssssss
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that anv
licensed Construction Supervisor, whether or not they have taken the permit are responsible for code compliance. (see
2.15.2 of section 5)
sass=sssssssssssssssssssssssssssssssss::::sssssssssssssssss:sssssss=:sasssssssssssssssssssssssssssssssss
1500 COST
Cost of Improvement S
Items to be installed but not included in the above cost: Electrical S
Plumbing
HVAC
Other
= Demolition - describe structure
Number of dwelling units Number of bedrooms A separate Refuse Disposal
Declaration required.
= 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 -roofing - (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 fL_ commercial)
Temporary structure - includes when allowed, trailers, tents and the I&e and only for limited periods of time.
Describe
500 CONSTRUCTION PLANS
/Z None submitted. Why?
- Submitted, usually three sets required. Four sets for food serviceluses. Number of sets submitted
600 SITE PLAN
0 Not required, why?
= Submitted When? - Previously, date C With this application
700 UTILITIES
Water supply - required _ yes X-o, 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 V —n , public sewer _ yes k-no
TOTAL $ I O O
private septic - on -site —xes _ no. Submit copy of permit as soon as available.
800 MECLIANIICALS & PRIMARY FUEL,
ArdAtectJEngineer - project supervision and reports
r-
= 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 SPRDflO.FM - 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 OFFSTREET PARKING - for ZONING & Architectural Access
NOT APPLICABLE
= Parking Plan submitted To = Building Department Z Planning Board Date submitted
Number of spaces - indoors outside total provided
H-ndicap 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 ves has it been issued ves — no �.
Submit copy of application and/or permit as soon as available.
1100 IDENTIFICATION (print or type except as noted)
Current owner - name bp A. Lr 'IFfJ 0 '�(
address T SM i M N F c K
phone # 0 / Ul
If corporation. officer in charge
Architect/En&eer - for overall design
Company name
Address
Phone number
Certified by State of Massachusetts as
Certification number
C
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)
Company name A Coo LS
Address 5- I ? smm el-,) -
Phone number 9F6 - 3 3 2-
Construction Supervisors license number Ql 3 3a-�;-
NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals and not
reproductions.
s:sss:sees:ss«sssssssssssss:sss:sssssss::sssssssssssssssssssssssssssssssssssssssssssssssss:sssssssssssss
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!
Ren_,)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