BP-56840SECTION 8 `=INSPECTOR'S REVIEW/COMMENTS
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RESIDENTIAL ❑ Approval In Part (Per 780 CMR.5111.13)
$25.00 APPLICATION FEE IS NON RE-F LE' It NON -TRANSFERABLE
' ' ! • DATE RECEV
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DARTMOUTH BUILDING DEPARTMENTNT 400 Slocum Road, P.O. Box 79399 �m I.tRy ?9 9 21
I At'I'LicAI IVN I WNSTRUGT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
1.1 Property Address: 7 % 1.2 Assessors MaJp�& Lot Number:
Lot Area (sf.) Frontage Map 0 " Lot T�
Required Provided
Front Yard 1.3 Historical District ❑ Yes 1p;No
Side Yard Has application been submitted to the Historic Commission?
Rear Yard ❑ Yes ❑ No Date:
1.4 Water Supply (MGL ii s54):
Municipal ❑ Privato
PLANS [
1.5 Sewage Disposal System:
❑ I,lunicipal J!�On Site Disposal System
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'SECTION 2 = PROPERTY OWNERSHIP/AUTHORIZED
AGENT
2.1 9wner Record:
1/2k3 J'�Vl
A,eA)l't) L (:V� �-Jlvl
Name (print)
Contact Add sS Phone Number
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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:
a
°) Signature: Telephone:
j3.2 Registered Home Improvement Contractor:
Not Applicable ❑ .
Are you a Home Improvement Contractor subject to (780 CMR.110.R6)? ❑ Yes []No
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:
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
❑ 1 am a Homeowner performing all the work myself.
Owners Name (print): , S,yt fT (�
Signature:
y 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
3.5 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0. effective July 1, 1982, no individual
Vallrube engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of buildings
tures, 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 unde is sectio ign below:
Signature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
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SECTION 4 -'WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL c'152 §`25)
Worker's 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 tUnecic all appucaDie)
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding er
(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 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) 5D D
(Please Print)
1, , as Owner of the subject property hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner
Date
1, t as-Owner/Authorized Agent hereby declare that the statements and information
the 6egoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pans a penalties of perjury.
Signatu a of Owner/Authorize gent Date
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