BP-11279Residential
1999
Residential 13 FOUNDATION ONLY 1999
1. Date plan reviewed:_
2. 30 days to review period expires:
3. OK to issue date:
4. OK to issue subject to requested submittals(see project review worksheet): Date:
5. DENIED (see project review worksheet): Date:
6. HOLD reason: "n�. l � I
ate'
7. HOLD, subject to Zoning Board of Appeals action:
8. Comments:
9. Inspector's Signature:
Applicant informed of above
Comments:
Total Permit Fee: $
TOTAL FEE:Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued To•
ouTH: DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O. Box 79399
Dartmouth, MA 0274737
155 ;icy f 508-999-0720 FAX 508-999-0738 I `+' - 7 s
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Zoning Review:
Energy Report:
Fire Chief -
Board of Health:
Conservation Cortrrission:
Other:
NUMBER OF PLANS SUBMITTED:
1.1 Property Addreas: n%
Signature:
_ Date:
Signature:
Date:
Signature:
Date:
Signature:
lute:
Signature:
Cate:
Signature:
Date:
_ _
Nearest Crosz- Street:v—,
Subdivision Name:
To
t<^l Land Area Sq. Ft.:
ater Supply (MGL c 40 § 54):
Name (print)
❑ Municipal❑ Private Well
SITE PLAN SUBMITTED:
1.2 Assessors Plat & Lot 1
Plate
❑ yes
❑ no
tuber:
I.ot.
_-
rusroncai uismet u yes u no
Has application been submitted to the Historic Commission?
❑ yes ❑ no Date:
❑ Municipal ❑ On Site Disposal System
Contact Address
(M--1 C:�
phone number
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uP�;,�P„taal 1999 Residential 1999
2.2 Authorized Agent:
Contact, Address
Name (print)
Telephone
....::.. RV
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor
License Numbers 6 '&C) Z-t
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!
f
cz� 01 ILL
Compa Name
Registration Number (if none, state "none")
Address
C�7j n
Q ` S`o O `1 S
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, MA 02108, (617) 727-8598
Owners Name (print)
Signature _
by signing the above, the home 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 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
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)
Wor
kers Compensation Insurance affidavit must be
completed an submitted with this application. Failure to
provide this affidav
it
It
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes ❑ no
❑ new ❑ addition ❑ alteration ❑ repairs ❑ chimney/fireplace ❑ woodstove
construction*
❑ deck ❑ accessory pool ❑ bldg. replacement window/door ❑ other ❑ demolition
P rY
(shed/garage) no. of windows I I doors (specify below t: (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 2no. of baths unit 2
Brief Description of ProposedfWork:
Item I Estimated Cost ($) to be completed by permit applicant
5.Total =(1+2+3+
* Estimated Total
(please print)
I, , 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.
Signature of Owner
I, , as Owner/)
the foregoing application are true and accurate, to the best
Signed under the pains and penalties of perjury. .
Print Name
Signature of Owner/Authorized Agent
Date
rereby declare that the statements and information
and belief.
Date
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