BP-62223❑ Approval in Part (Per 780 CMR.5111.13)
DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT
_ 400 Slocum Road, P.O. Box 79399
Z Dartmouth, MA 02747 l i i 3: o%
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
Zoning Review: Signature: 4g��" bate:
� u 2 1 nttf
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other: Signature: Date:
Brief description of work being performed: j'Z--
1.1 Property Address: 3/S 1614& No Ad, JCL
Lot Area (sf.) 7 6---d 66 Frontage
Required Provided
-��Cnt Yard
Si&,Yard
Rear Ya.,
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disp pal System:
2 Municipal ❑ Private Well ❑ Municipal Site Disposal
2 Assessors Map & Lot Number:
Map �5 Lot 3 S -
1.3 Historical District ❑ Yes 640
Year Built
❑ Altering more than 25% per side of building
Has application been sitted to the Historic Commission?
❑ Yes IX o Date:
CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
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RESIOIL' N12 TIAL
ERSHII UTd !ORIZED.AGI=' .;
2.1 Owner Record,
^`1L-CT'
° 7 ��
A%t?G'iA,-l.
Name (print)
Contact Address Phone Number
2. Authorized Agent:
i C,.
77
Name (print)
Contact Address f Phone Number
... ^: .. wr' -� ,✓�... F,.. -q�3E iry .,, aS '_' `fib' _... �lsy ,,,.� y f.:
� .. ',.SEGZIOfd 3 : CONSTRtlGTION SERVICES
3.1 Licensed Construction Supervisor/Specialty License:
License Number:
Company Name/Contractor Name:
Address:
Expiration Date:
-Signature: Telephone:
3.2 R istered Home Improvement Contractor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR.110.R6)? ❑ Yes ❑ No
Are you claming exemption from the requirements? ❑ Yes []No
If Yes, Go to Section 3.3
Comorny Name/Contractor 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, MA 02108, 617-727-8598
am a Homeowner performing all the work myself.
Owners Name (print):
I
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
6108.3.5 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individua
shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of building
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 Constructioi
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 Homeowne
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 whic
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 tha
one home in a two-year period shall not be considered a Homeowner
If you are applying under this section sign below:
C
Signature: `� ,
Y66r signature carries certain responsibilities, Including but not necessarily limited to, general liability
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