BP-60089RISI®ENTIAL ❑ Approval in Part (Per 780 CMR.5111.13)
S25.00 APPLICATION FEE IS NON BE -FUNDABLE & NON -'IWI&S� ftABLE
DATE RECEIVED
,1rk. DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O. Box 79399 2 liii I'iff 26 PH 4: 24
Dartmouth, MA 02747
Phone: 508-910-1820 Fax: 508-910-1838
www.town.dartmouth.ma.us
APPLICATION TO COJVSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Zoning Review: Signatura—.-- ., �'�'
l/J'�-t Date: JUN ' 2010
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: _
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
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RESIDENTIAL
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SECTION,2 - PROPERTY, (7`�IN�S�f1P�AUTHORIZE
AGEhiT��.,.
2.1 Owner Record: r
5 -5--n ! 774
Nam prim/ `O /
Contact Address Phone Number
2.2 Authorized Agent:
�r
Name (print)
s� Iawne Number
Cordact Add
�'`72Zcs�Z
Si CTtON 3,� CONSTRUCTION. SERVICES
3.1 Licensed Construction Supervisor/Specialty License:
License Number: Ceo
Company Name/Contractor Name: 6,
Address:. �-- �� �•
Expiration Date:
91 -q 1 b
Not Applicable ❑
Signature: Telephone. ,1zZ,�
3.2 Registered Home Improvement Contractor.
Are you a Home Improvement Contractor subject to (780 CMR.110.R6)? 2"Yes ❑ No
eo
Are you claming exemption from the requirements? ❑ Yes la
If Yes, Go to Section 3.3
Company Name/Contractor Name: • !? vl_!5;eW4C_D
Registration Number (if none, state "none"):
�G ���
-Address:`--L[��✓'� , v✓ %�i� �, Q.
� c
Signature:- Telephone:
Expiration Date: Lj
3.3 Fo idential Remodel ork Only
PERSONS CONTRA WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GU FUND:
QUESTIONS OR COMPLAINT r write:
Home Improvement Contractors tration, One Ashburton Place - Room 130 ston, MA 02108, 617-727-8598
❑ 1 am a Homeowner performing all the wo
Owners Name (print):
Signature:
ping the above, the homeowner acknowledges that there will be no eligibility to the Guaranty
Date:
3.4 eowner Exemption - One & Two Family Only
OMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PRO
5108.3.6 Licensing of Construc upervisors: Except for those structures governed by Construction Control in Section 116.0, eff . my 1, 1982, no individua
shall be engaged in directly supervising perso �e4gaged in construction, reconstruction, alteration, repair, removal or demolition � ving the structural elements of building
or structures, unless he or she is licensed in accordanct-w' J the rules and regulations promulgated by the BBRS entitle es and Regulations for Licensing Constructioi
Supervisors.
Exception: Any Homeowner performing work for which a Building Per i quired shall be exempt 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 s isor
For the purposes of this section only, a "Homeowner" is defined as follows: Perso ns 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 detac ructures accesso uch use and/or farm structures. A person who constructs more tha
one home in a two-year period shall not be considered a Homeown
If you are applying under this sect' Ign 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 p ide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: PlYes ❑ No
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. B"Roofing/Siding ❑ Other
(Energy 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:
Single Family: No. of Bedrooms No. of Baths
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 eroposed work:
Item I Estimated Cost M to be completed by oermit applicant
1. Building
2 tf€Ieel-_
3=oi,
5. Total =(1 +2+3+
(Please Print) _
I,t7F-�l� J- 17+ as Owner of the subject property hereby authorize �—`�J
to act on my behalf, in all matters relative to work authorized by this building permit application.
a
Sidnature of Owner Date' /
I, f /-r'i /- - 0, ! E! � —4//-4� , 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.
Sigrfature of Owner/Authoriz d Agent Date
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