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BP-63134SECTION 12 -`ESTIMATED CONSTRUCTION COST ":< COMMERCIAL i Item Estimated Cost ($) to be completed by permit applicant 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Off -Street Parking 6. Total = 0 + 2 + 3 + 4 + 5) Estimated Total Cost Including Labor. $ Pon , SECTION 13A OWNER AUTHORIZATION S ( . p . 1 �to"6e"com leted when owner's agent or contractor applies for,building permit) (Please'Print) I, , 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 SECTION`13B'-OWNERIAUTHORIZEDAGENT, DECLARATION A)`i`O w. 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 un r the pains and penalties of perjury. f y%6/toll Sigtfature of Owner/Authorized Agent Date ;»SECTION 14 - INSPECTOR'S-REVIEW/COMMENTS:, 1. Date Plan Review: 2. 30 Days to Review Period Expires: 3. OK to Issue Date: 4. Per M�CMR 111.1 Rejection Letter Sent: 5. HOLD - Reason: D_Ls D n2_e, Date: MAY ® 5 2inig r 6. HOLD - Subject to Zoning Board of Appeals Action: 7. Comments: 8. Inspector's Signature: Date: APPLICANT NOT �i Applicant informed of above. Date. Time: 0 Clerk. Comments: SECTION 16'-:OFFICE/INSPECTOR'S'NOTES` / Less Application Fee: $25.00 Remaining Balance: $ �b Total Permit Fee: $ �5 Other $ Amount $ TOTAL FEE: Gross Area - New Construction total sq. ft. Gross Area Alteration total sq. ft. Permit Issued to: Yj?�r��v� /A JW't" �J 6Q fix! �/''t J4 eE: e� KrIM R3 1'%Ui1 AIM-rU.,�a KY11W"1.r' 6iL r DATE RECEIVED DARTMOUTH BUILDING DEPARTMENT25 400 Slocum Road, P.O. Box 79399 t Dartmouth, MA 02747 _�� ' Phone: 508-910-1820 Fax: 508-910-1838 www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A COMMERCIAL BUILDING(inciuding3ormorefamilydwellings) 1.1 NUMBER OF PLANS SUBMITTED: 1.2 SITE PLAN SUBMITTED: ❑ Yes 'L5-No 1 )<3 Property Address: 1.4 Assessors Map & Lot Number: Map 2- © Lot Nearest Cross Street: q"A ap,? � �^ 1.5W,ate� Supply (MGL c404): Business Name: 1 4iAZI / Ei Municipal Cam]-frdvate Well Business Phone #: �0 '�I �! : 45-rcl i , 1.6 Sewage Disposal System: Total Land Area Sq. Feet: 1A K /� C3-Idunicipal ❑ On Site Disposal System SECTION 2 - PROPERTY OWN ERSHIP/AUTHORIZED":AGENT 2.1 Owner Record:A9, (K tl f(� Name (print) kontact Address Phone Number 2.2 Authorized Agent: S'CtTot e S Q H^,r me (print) Contact Address Phone Number Page 4 Page 1 Revised 9/09 SECTION 3 = CONSTRUCTION SERVICES' 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number: Address: Expiration Dater Signature: Telephone: SECTION 4 -WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL c 152 § 25)" - " 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 (MGL 152 Section 25A). Signed Affidavit Attached: ❑ Yes ❑No ``SECTION 5 -.DESCRIPTION: OF PROPOSED WORK (Check all applicable);'- J o New Construction ❑ Addition ❑ Repairs ❑ Accessory Building (Shed/Garage/Other) ❑ Other (Specify Sec. 6) emolition ❑ Sign ❑ Replacement window/door No. of Windows Doors ❑ Fire Protection - SECTION 6 ='PROPOSED PROJECT USE ='INCLUDING THREE FAMILY OR -MORE AND EXEMPT USES The following descriptions are based on the Massachusetts State Building 7th Edition, Code Article 3, as noted. See the Code. ❑ Assembly - restaurant, lounge, theater, school, etc. (see Code Section 303.0) Describe: ❑ Business -office, assembly with less then 50 occupants - indicate Medical or other professional (see Code Section 304.00) ❑ Education - struction for training including child day care for those over 2 year 9 months (see Code Section 305.0) ❑ Factory/Industrial (see Code Section 306.0) ❑ High Hazard (see Code Section 307.0) ❑ Institutional -hospital, nursing home, infant daycare (see Code Section 308.0) ❑ Mercantile - retail stores (see Code Section 309.0) ❑ Residential - three or more family, hotel (see Code Section 310.0) ❑ Storage - including garage (see Code 311.0) ❑ Utility & Miscellaneous Structures - includes tents and agricultural structures (see Code Section 312.0) ❑ New Tenant - for any of the above, please indicate (see Code Section 110.0) ❑ Tent or Trailer - temporary Purpose? " ❑ Other: Describe the proposal, INCLUDE number of dwelling units and bedrooms or occupant load as applicable, also existing condition (if extra space is needed, attach an additional sheet): YJ i < V�s� rQ C. C&I t,J SECTION 7 -:TYPE OF CONSTRUCTION OR WORK TO`BE PERFORMED ❑ New construction and/or Additional (total gross cubic feet proposed) - indicate If the project is an addition to existing structure - total gross square feet of existing: ❑ Alteration of existing, no increase in gross square feet. A separate Refuse Disposal Declaration is required. Will this project be subject to CONSTRUCTION CONTROL (over 35,000 cu. ft.) ❑ Yes ❑ No If Yes, see Code Section 116.0 Designer to submit Code Synopsis in additional to original plans and if existing building Section 3402.1.1 Will this project require Peer Review (over 400,000 cu ft.) ❑ Yes ❑ No (see 110.11.1 Code) APPLICANT TO PROVIDE PEER REVIEW AT THEIR EXPENSE. SEE 780 CMR. Page 2 ❑ Demolition* - describe structure: ❑ Trench Permit Required? ❑ Yes ❑ No See Trench Requirements G.L.C. 82A and 520 CMR 7.00 et seq. ❑ Moving* - (provide copy of DPW moving license) "Type of structure: from where (map/lot or address): to where (map/lot or address): number of dwelling units: number of bedrooms per dwelling unit: ❑ Replacement doors and windows - (for existing only) (only where doors and dows exist and will not be enlarged) EGRESS dimensions must be maintained. ❑ Temporary structure and uses - includes, .when allowed, new tenants, trailers, tents and the like and only for limited periods of time. Describe: °SECTION 8 - MECHANICAL & PRIMARY FUEL " ❑ 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) Roof Top nit (RTU) New ❑ Replacement ❑ ❑ None of the above to be provided Mechanical Ventilation ❑ ❑ Hot Water: Gas Electric Fuel Oil Other SECTION 9 SPRINKLERS AND/OR FIRE`PROTECTION'-3COPIES OF `PLANS' AND NARRATIVE REQUIRED ❑ Required: plans provided plans not provided, why? ❑ Not required, not to be installed, why? Narrative Submitted? ❑ Yes ❑ No SECTION 10 - REQUIRED; OFF-STREET FA NG for Zoningand Architectural Access . ❑ Parking plan submitted to: Building Dept. Planning Board - Date submitted Number of spaces indoors outside Total provided Handicap spaces required Yes No if Yes, how many as a part of the total required number Is Route 6 (State Road) entrance permit required? 'Yes No if Yes, has it been issued? Yes No Submit copy of application and/or permit as soon as available. SECT 10411 -:IDENTIFICATION ' 11.1 ArchitectlEngineer - for overall design Company Name: Address:' Phone #: Certified by State of Massachusetts as: Certification Number: Note: Signatures and seals on all plans affidavit & other documents SHALL BE originals and not reproductions. -11.2 Architect/Engineer project supervision and reports Company Name: Address: Phone #: Certified by State of Massachusetts as: Certification Number. Note: Signatures and seals on all laps vdavits & other documents SHALL BE originals and not reproductions. 11.3 General Contractor Company Name: Address: 77 Phone #: Construction Supervisors L' ense Number: Note: Signatures and sea s on all plans affidavits & other documents SHALL BE originals and not reproductions. Page 3