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BP-48645SECTION 8 INSPECTOR'S REVIEW/COMMENTS 1. Date plan reviewed: 2. DENIED (see project review worksheet): Date: 3. HOLD Reason: Date: 4. HOLD subject to Zoning Board of Appeals action: Date: Comments: SECTION 10`- OFFICE/INSPECTOR'S NOTES Less Application Fee: $25.00 Remaining Balance: $ 9 Total Permit Fee: $ 0 o2 0 Other $ Amount $ TOTAL FEE: %Q 'R 0 O' C Gross Area - New Construction total sq. ft. % Gross Area - Alteration total sq. ft. Permit Issued to: % /O Al %'y 0 A- C -, s i i-v q /�� n�,� (� 4 /a Q /21/1 Eli 7-/t 0 11110 116 e QA" 5 tj' ,v le a An SECTION ADDITIONAL °COMM ENTSISKETCHES = -- �� - SDN /Zdv�% G kAll G 't7. 6 KJV,= 13� 6 4s 1L T .L?. ` Y3� 114-7 7 � X - a s• � � 76' 0 i et 1417 a« ❑ SPECIAL PERMIT (Per 7R0 CMR 111.13) w DATE, RECEIVED DARTMOUTH BUILDING DEPARTMENT �. �. 400 Slocum Road, P.O. Box 79399 Dartmouth MA 02747 r r Fi 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 n. I THIS SECTION FOR OFFICIAL USE ONLY O.K. TO ISSUE Zoning District: Zoning Review: Signature: Date: Energy Report: Signature: -4) Date: z �+� Fire Chief: Signature; Date: Bard of Health: Signature: Date: Os�rvationCommission: Signatur Date: Other: Signature: Date: Brief description of work being performed: C nJ SECTION 1 -SITE INFORMATION 1.1 Property Address: q � [, rF''Vlri i 90A)g 1.2 Assessors Map & Lot Number: Nearest Cross Street: Map Lot_ Subdivision Name: �C 1.3 Historical District ❑ Yes C�'No Total Land Area Sq. Feet: r Has application been submitted to the Historic Commissio-? ❑ Yes ❑ No Date: 1.4 Water Supply (MGL s54): 1.5 Sewage Disposal Syste ❑ Municipal Lla Private Well ❑ Municipal On Site Disposal System ® CONSTRUCTION PLANS SITE PLAN DENERGY REPORT r RESIDENTIAL NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner Record: - Name (print) (P ) Contact Address Phone Number Authorized A ent: 1 1 -IV 1 �)l l 6 r 6(1T1� ��S r� 2R, q- 6 I�'fame (print) Contact Address Phone Number SECTION 3 -'_CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number: �607 p Address: 16 u M Expiration /Date: "/ I,;�l Signature: � a Telephon q ^ ( _6 t 3.2 Registered Home Improve ent 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 claming exemption from the requirements? ❑ Yes ❑ No If Yes, submit the required affidavit! Company Name: UG/; ln/ j , n/ Registration Number (if none, state "none"): Address: Signature: Telephon ] —� U'J Expiration Date: glwlo s 3.3 For Residentia Remodel ork 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 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 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 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'SCOMPENSATION INSURANCE AFFIDAVIT (MGL c 152 § 25) Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to rovide 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) ❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other (En rgy 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: 1 Single Family:No. of Baths.. No. of Bedrooms % Two Family: No of Bedrooms Unit 1 No. of Baths Unit 1 No of Bedrooms Unit 2 r 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 iDelectricity, 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 Description of proposed wo : LI�7/o SECTION 6 -'ESTIMATED CONSTRUCTION COST Item Estimated Cost ($) to be completed by permit applicant 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Total=0 +2+3+4) SECTION 7A - OWNER AUTHORIZATION,,. . _. (to b/e+ completed when owner's agent or contractor applies for building permit) (Plea Print) �81 re Jy J property Y I, 1 CJ y , as Owner of the subjecthereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. /,I p7' igna urg of Owner I ; nn Date t ;SECTION B - OWNER/AUTHORIZED AGENT DECLARATION I, UGE tv /j�rY , 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. Signed under the pain and penalties of perjury. 1M" ��Ja z Signature Owner/Author' ed Agent Date