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BP-24062RESIDENTIAL 2002 SECTION 8 ?INSPECTOR'S REVIEW/COMMENTS 1. Date plan reviewed: l� 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 Norksheet): Date: 6. HOLD reason: Date: 7. HOLD subject to Zoning Board of Appeals action: Date: S. Comments: 9. Inspector's Signature: Date: '61 SECTION 9 - A L CANT NOTIFICATION 42 Applicant informed of ab e Date Ti e: Clerk: Comment SECTION 10- OFFICEVNSPECTOR'S NOTES Total Permit Fee: $ �_1,•._ `� lJqVess Application Fee: $ 25.00 Remaining Balance: w �' TOTAL FEE: • � jj Gross Area - New Construction total sq. ft. Gross Area = Alteration total sq. ft: Permit Issued To- c- SECTION 11 - ADDITIONAL COMDIENTS/SKETCHES X__ e_5*r_1114;1 L c� U It RESIDENTIAL 2002 ❑ FOUNDATION ONLY $25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE DATE RECEIVED DARTMOUTH BUILDING DEPARTMENT 400 Slocum Road, P.O. Box 79399 .:/ Dartmouth, MA 02747 , 1,?4-___ 508-910-1820 FAX 508-910-1838 APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING THIS SECTION FOR OFFICIAL USE ONLY RECEIVED BY: BUILDING PERMIT DATE SENT FOR REVIEW: NUMBER: DATE ISSUED: OK TO ISSUE - SIGNATURE: DATE i " Build' ,- Commissioner/Insp 44of Buildings Zoning District:��roposed Use: Zone: C B ❑ A ❑ V Outside Flood Zone ❑ Aquifer ZoneL�_ THE FOLLOWING AGENCIES SHOULD BE NOTIFIED: ❑ Board of ❑ Board of ❑Con. Com. ❑ Demo ❑ DPW ❑ Elec. ❑ Energy Report Appeals Health Affidavit Card Sent: Cut Off Follow-up* ❑ Fire ❑ Gas ❑ Planning Board* ❑ Sewer Card ❑ Water Card ❑ Zoning ❑ Other Chief Cut Off / Cut Off / Cut Off Review* * REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERbIIT. DEPARTMENTAL APPROVAL Zoning Review: Signature: Date: Energy Report: Signature: Date: Fire Chief: Signature: Date: Board of Health: Signature: Date: Conservation Commission: Signature: Date: Other: Signature: Date: ' Description of work tieing peifornted: SECTION 1 - SITE INFORMATION NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes ❑ no ttJJ3 1.1 Property Address:7?�� 1.2 Assessors Plat &Lot Number: 2 Plat Lot/ - Nearesf Cross Street: r �C�..1,e U cuwoo j1GE 1.3 Historical District ❑ yes ❑ no Subdivision Name: Has application been submitted to the Historic Commission? Total Land Area Sq. Ft.: 7ItdOC� ❑ yes ❑ no Date: 1.4 Water Supply (MGL c 40 5 54): 1.5 Sewage Disposal System: C3" Municipal❑ Private Well ❑ Municipal ❑ On Site Disposal System C:\bldg.forms\Bldeapp.res.u'pd Pace 4 Rey. January 19. 2001 Rev. January 19. 2001 RESIDENTIAL 2002 RESIDENTIAL 2002 SECTION 2 - PROPERTY OWNERSHIP AUTHORIZED AGENT - 174am— `X9.2-7/Z/ 2.1 Owner of ecord: 4 _-bT A4 Y j cf1-77 e.,SUSAA1 r T(V YY 3 Sr, /ram M Fe- V_ 0'JT u Name (print) Contact Address Phone Number 2.2 Authorized Agent: Name (print) Contact Address Phone Number SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor License Number 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! Company Name Registration Number (if none, state `none") Address 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, A1A 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 i, 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 6N ns 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 dwellins, 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 u er this se to s' below: Signature: IV -our 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) SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL C 152 § 25) Workers 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. Signed Affidavit Attached: ❑ yes ❑ no SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable) ❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ ❑ woodstove (energy report required) (energc�y report required) fireplace ❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ demolition (shed/garage) no. of windows doors (specify below): (specify below): If new construction, please complete the following: Single Family: no. of bedrooms no. of baths Two Family: no. of bedrooms unit I 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 fitel, natural gas, propane, electricity, other (specify): ❑ Air conditioning - (separate unit) ❑ None of the above to be provided ❑ Hot Water: Gas Electric Fuel Oil Other Brief Description of Proposed Work: iG GJ "�..�=i"=rr S°v0►- /11 G�.! FP_ 0N( FA km -c-e-s Per— c— " tvv SECTION - 6 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (S) to be completed by permit applicant 1. BuildmLT _'. Electrical '. Plumbin�� 4. Mechanical Hy'AC �. Total = (1 - 2 + 3 + 4) * Estimated Total $ SECTION 7A - OWNER AUTHORIZATION (to be completed when owner's agent or contractor applies for building permit) (please print) I, v/� fLf t Trtf , as Owner of the subject property hereby authorizd ? � ,, rr�.cc to act of my behalf, ' tnattirs relative to work authorized by this building permit application. .0 y c7--ICY z Signature of Owner Date SECTION 7B - OWNER/AUTHORIZED AGENT DECLARATION I, Zd� I'vrr711r/� 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 � the pains a enalti s of perjury. Signature of Owner/Autliorized Agent Date G C� c TX Alft it •. OIL ' �' *NW -.Iclt • r C o YOUR Ds��a�e 'v� i'iS�T GL S�� THE i, b�l`��V ��G�� i �� i • �' AT Tf1': FitlS3_D1�iC Dt�`?SNG T gggg yy,, tip°' ��Tyy TZ 3 58 •Y� b'+i`;,z. a F''9 yey��4 �� per- F# . Man,�QSa f.3 .f ��'yyN �'9 '� Yey �al�� :1 DO �)�a� Eli cCa SONO-TU • ' "'!"E M'D DEPTH I':D E.Er=OP! *� lS4�PECTIOi� IS MI-O.'J+ THE CONO-BETE IS POURED. BUILDING DF-PA 'sTV " % a fi Ta mn of Daftmo ."ell ;. 4 a 41 CIAZI prK h N t�h W tj �3f'' GwjtiC�p`S 'D egt y rn R AT TLI :. C-J€;.CticyG DURING THE OF THIS WORK. BUILDING DEPARi149Ei`i`[" Town of Daartnncu'.,h .