BP-612461. Date plan reviewed:
2. DENIED (see project reviewworksheet):
3. HOLD % J�
Reason: y
4. HOLD subject to Zoning Board of Appeals action:
Comments:
Inspector's Signature:
Applicant informed
Comments: 'r
PECTOR'S REVIEW/CO
SEP 3 0 2010
Less Application Fee: $25.00
Total Permit Fee: $ /
Other $ Amount $
Date:
Date:
Date:
Date: SEP 3 0 2010 I
Remaining Balance: $ " — o
TOTAL FEE: Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to: r
REST ®ENT'A1 ❑ Approval in Part (Per 780 CMR.5111.13)
$25.00 APPLICA ION FEE 1S NON HE -FUNDABLE a&,1dWN-,'1'JMAANFkJKABLE
zDATe.RECEIVED
OLIrN �. DARTMOUTH BUILDING DEPARTMENT,
400 Slocum Road, P.O. Box 79399 Nj` i 2
z Dartmouth, MA 02747
°� Phone: 508-910-1820 Fax: 508-910-1838
1664
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Zoning Review: Signaturex.&.4--i--C,P . Date: SEP 3 0 2010
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: Date: "
Other: Signature: Datte:
Brief description of work being performed. W S :WN Q�t ►ti-�L
1.1 Property Address: 5' 6M IT 1.2 Assessors Map & Lot Number:
Lot Area (sf.) Frontage Map _��_ Lot o2-! -
Required Provided
Front Yard 1.3 Historical District ❑ Yes ❑ No
Side Yard Has application been submitted to the Historic Commission?
Rear Yard ❑ Yes ❑ No Date:
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System*
L9'Municipal ❑Private Well ❑Municipal n Site Disposal System
CONSTRUCTION PLANS SITE PLAN ENERGY REPORI
RESIDENTIAL
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT '(MGL'c 152 §`25)
SECTION 2 -`PROPERTY OWNERSHIP/AUTHORIZED
AGENT"_-
2.1 Owner Record:
l j -
Name (print)
Contact Address Phone Number
2.2 thorized A
-r
Nam (prino
Contact Address Phone Number
SECTION 3 -CONSTRUCTION.SERVICES
3.1 Licensed Construction Supervisor /Specialty License
Not Applicable ❑
Licensed Construction Supervisor /Specialty License
License Number: CS 74644
t�
�!
Address:
Expiratio Date:
Signatur • Telephone:g
I -i,
V3.2
Registered Home Improvement Contractor:
Not Applicable ❑
o
Are you a Home Improvement Contractor subject to 80 CMR.110.Rti
If No, go to the next section!
Are you claming exemption from the requirements? ❑ Yes ❑ No
If Yes, submit the required affidavit!
Company Name: `
Registration// Number (if none, state "none"):
Address:
Signature: Telephone:
Expiration Date: JZ
3.3 For Residential Remodel W=Onlyy
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
0 1 am a Homeowner performing all the work myself.
Owner`3 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
5108.3.5 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
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to pro a this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: es ❑ No
❑ Deck ❑ Pool
❑ New Construction*
(Energy report required)
❑ Addition
(Energy report required)
RIPTI
❑ Repairs ❑ Alteration
❑ Accessory Bldg.
(Shed/Garage)
V'Replacement window/door
No. of windows 8 Doors
*If new construction, please complete the following:
Single Family: No. of Bedrooms
No. of Baths
❑ Chimney/Fireplace
❑ Roofing/Siding
❑ Woodstove/Pellet Stove
❑ Other
(Specify below)
❑ Demolition
(Specify below)
Two Family: No of Bedrooms Unit 1 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
❑ Air conditioning : (separate unit)
❑ None of the above to be provided
❑ Hot Water. Gas Electric Fuel Oil Other
Description of proposed work:
Item Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total =(1+2+3+4) /
(Plea e Print) /�,
I, {T! , as Owner of the subject property hereby authorize o t4 V-S on
to a n my behalf, in all matters relatYve to work authorized by this building permit application. IJ
Si t e of Owner Q Date
I, dr rLLZLl ��1� 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 pains and penalties of perjury.
S!griature of Owner/Authorized A ent Date