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BP-32920RESIDENTIAL ❑ FOUNDATION ONLY :5L5.UU APPLICATION FEE 15 NON-REFUNDABLL & NUN-T1KA1N5FEKAA5AmK 2004 1. Date plan reviewed: ✓?�/lm` 4 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: Date: 7. HOLD subject to Zoning Board of Appeals action: Date: 8. Comments: 9. Inspector's Applicant informed of above Date: 3 S o Time: j" Comments: _,&/,� SEGTI0 1Q- ,OFFICEVNSPECT©WS 1 OI �ffp gym. � Total Permit Fee: $ 3O•o(f) Less Application Fee: $ 25.00 TOTAL FEE: 30 , OD Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. ft. Permit Issued To: &5&& 'C-u � Te Remaining Balance: $ COCA RESIDENTIAL 2004 ❑ FOUNDATION ONLY $25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE T""' ` I� 'DATE RECEIVED DARTMOUTH BUILDING DEPARTMENT 400 Slocum Road, P.O. Box 79399 �- 5 Dartmouth, MA 02747 f " 12. 51¢ 508-910-1820 FAX 508-910-1838 APPLICATION TO CONSTRUCTJiEP JR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING Zoning Review: Energy Report: Fire Chief: Board of Health: Conservation Commission: Other: Description of work being I NUMBER OF PLANS SUBMITTED: Signature: Date: Signature: Date: Signature: Date: Signature: Date: Signature: Date: Signature: Date: SITE PLAN SUBMITTED: ❑ yes ❑ no 1.1 Property Address: *�/�++y 3 z �� Plat�^ Lot 1.2 Assessors Plat & Lot Number: �� �- �,,,%� Nearest Cross Street: C.. Subdivision Name: 1.3 Historical District ❑ yes ❑ no Total Land Area Sq. Ft.: ��QGU, �, Has application been submitted to the Historic Commission? ❑ yes ❑ no Date: 1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System: C:\bldg.forms\BIdgapp.res.wpd Page 4 Rev. January 1, 2003 C:\bldg.forms\Bldgapp.res.wpd ❑ Municipal ❑ Private Well Page 1 ❑ Municipal ❑ On Site Disposal System Rev. January 1, 2003 RESIDENTIAL 2004 RESIDENTIAL 2004 �` S1 TIt7N Z i'Rt' 0 Tay, 1 AGENT 2.1 Owner of Record: KeyI h 4trz,Sty► Y',C/ �9..2 ' 7/ J/ dl Kgd Name (print) Contact Address Phone Number 2.2 Authorized Agent: t 577uL k. 573 l3 � Contact Address Phone Number Name (print) SECTION rcCONSTRLTC I it3i ERR itIC1 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor License Number C$ 07-16,j Address olo'.11)ka Expiration Date Signature /'rd 144- Telephone _,qfQ l3S S 7q 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 t�+ Registration Number (if none, state ❑ none❑) l ZC7W Address �j 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 dwelline, 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 i NOTICE T LICENSED CO. o �^rRACToxs. The Bmldmg Code provides in the Rules and Regulations section that any licensed Constructlon Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15) 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 ❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ (energy report required) (energy report required) fireplace R deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other (shed/garage) 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 I 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 (specify): ❑ Air conditioning - (separate unit) ❑ None of the above to be provided ❑ Hot Water: Gas Electric Fuel Oil Other Brief Description of Proposed Work: A M01.1 mmm:mmT ❑ woodstove ❑ demolition (specify below): Item I Estimated Cost ($) to be completed by permit applicant 5.Tota1=(1+2+3+4) of * Estimated Total $ -), /1p dr , as Owner of the subject property hereby authorize relative to work authorized by this building permit application. Date 1, I/(^ti`' I— - v , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing Ilication are true and accurate, to the best of my knowledge and belief. Signeduer the n penalt' f perjury. Signat re Owner/Authorized Agent Date C:\bldg.forms\Bldgapp.res.wpd Page 2 Rev. January 1, 2003 C:\bldg.forms\Bldgapp.res.wpd Page 3 Rev. January 1, 2003