BP-24818SECTION 8 - INSPECTOR'S REVIENV/CONINIENTS
1. Date plan reviewed:
?. 30 days to review period expiroa:
3. OK to issue date:
4. OK to issue subject to requested submittals(see project review worksheet): Date:
5. DENIED (see project review xorkslieet): Date:
6. HOLD reason: Date:
7. HOLD subject to Zoning Board of Appeals action: Date:
8. Comments:
9. Inspector's Signature:
DJUL 0
E
TIO 9 - A90LICANT NOTIFICATION
Applicant informed f abov Dat :Ti Clerk
Comments:
SECTION 10- OFFICEVNSPECTOR'S NOTES
Total Permit Fee: S
Less Application Fee: S 25.00
Remaining Balance: S
TOTAL FEE: " 1 5_'�Gross Area - New Construction total sq. ft.
� Gross Area - AI ration total sq. ft.
Permit ssued To•
1
SECTION I I - ADDITIONAL CON NIENTS/SKETCHES
U V UUJVUAJJUJV UIVL,,r
$25-00 APPLICATION FEE IS NON-REFUNDA13LE & NON-TRANSFERAIRLIE
r~ DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O. Box 79399
DATE RECEIVED
Dartmouth, MA 02747
E .
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
HIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY:
BUILDING P
DATE SENT FOR REVIEW: i
NUMBER 9�
DATE ISSUED•
OK TO ISSUE - SIGNATURE: DATE�)iJJ
�inommissioner/ �tr�B.iings
ss
Zoning District: L�1
oposed se- Zone: 'C ❑ B ❑ A ❑ V Outside Flood Zone ❑ Aquifer Zone
THE FOLLOWING A9tNCIES SH LD BE NOTIFIED:
❑ Board of ard of ❑Con. Com. El Demo ❑ DPW ❑ Elea ❑ Energy Report
\Qea101th
Appeals Affidavit Card Sent: Cut Off Follow-up*
❑ Fire ❑ Gas ❑ Planning Board* ❑ Sewer Card ❑ Water Card ❑ Zoning ❑ Other
Chief Cut Off / Cut Off / Cut Off Review*
* REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPARTMENTAL APPROVAL
Zoning Review: Signature:
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other: Signature: Date:
r
Description of work behil peifornted:
SECTION 1 - SITE INFORMATION
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes ❑ no
1.1 Property Address: I SS G�4t= (-'tt�Fy %� t!1-1)
1.2 Assessors Plat of Number:
Plat Lot -
Nearest Cross Street:
1.3 Historical District ❑ yes ❑ no
Subdivision Name:
Total Land Area Sq. Ft.:
Has application been submitted to the Historic Commission?
❑ yes ❑ no Date:
1.4Water Supply (MGL c 40 § S4):
1.5 Sewage Disposal System:
❑ Municipal Private Well
❑ Municipal On Site Disposal System
C:`bId_.forms\BId_app.res.wpd
Passe 4
Rev. Ja1lUary 19, 2001
C:+1dg.11)nns Bld_app.res.\kpd
Pa-e 1
Rev. January 19, 2001
RESIDENTIAL 2002 RESIDENTIAL -2002
SECTION 2 - PROPERTY OWNERSHIP / AUTHORIZED AGENT
2.1 Owne' r of Record:
Cl-Aup Cifi2�ST/n!E GPI -(&-'A S
1 SSG Fr&'Q (9-W634-603 Y
Name (print) - :
Contact Address Phone Number
2.2 Authorized Agent:
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 claiming exemption from the requirement? ❑ yes ❑ no
If yes, submit the
required affidavit!
Company 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, IV.4 02108, (617) 727-8598
f
' c DG CTC�i���
Ow ners Name (p t)
Signature
by signing the above the e 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 T 16.0, 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 engagtis 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 hortie in a two-year period shall not be considered a Homeowner.
If you are appi n r this section sign below:
Signature: _ _ ..
Your signature caYrigj rtain esponsibilities, 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 ❑ alteration ❑ repairs ❑ chimney/ ❑ woodstove
(encrgt• report required) (enet ay report required) fireplace
❑ deck Lg pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ demolition
(shed/garage) no. of windows doors (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 I 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: k) 3 0 v azeO cw ae
5A4 otex
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (S) to be completed by permit applicant
1. Building
�. Electrical
�. Plunibine
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4)
* Estimated Total S SOO O o0
SECTION 7A - OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(please print)
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.
Signature of Owner Date
SECTTON 7B - OWNER/AUTHORiZED AGENT DECLARATION
I, C L �U �� G EL(AH� ,-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.
Signld r the pains and penalties f perjury. e
Signature of Owner/Authorized A ent Date
in 1nni
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PROGRESS OF TH!S WORK.
BUS' DWG DEPARTMENT
Tcwn of Dartmouth
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A Copy W, This Eldad
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AT TNF BUILDING OURING TH'�
p,"'A # ?rSS OF THIS WORK.
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AT THE CUILDING DURING THE
PROGRESS OF THIS WORK.
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SONO-TUDE SIZE AND DEPTH
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CVLDING DEPARTMENT
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