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1600 TO THE APPLICANT/REFERRAL AND AppROV
Date of Application submission
Plat Lot Street
tfer e
Owner
Owner mail address
Owner phone #
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OTHER INVOLVED AGENCIES - The following agencies require separate jurisdictionarmits or approval for your
proposed project. CONTACT 771EM FOR RF SUBMISSIONS.
® TAX COLLECTOR = Approved HOLD By
Date
❑ Board of Appeals _ Approved By
Date
❑ Conservation Commission C Approved By
Date
❑ D.P.W. Water _ Approved By ___ 13 D.P.N. Se er = Approved By
Date
❑ D.P.W. Cross Connection = Approved By
Date
❑ Treasurer (Bond) ❑ Approved By
Date
❑ D.P.W. Engineering - Approved By
Date
7 Boars' of Health (well) = Approved By
Date
❑ Board of Health (septic) = Approved y
Date
❑ Board of Health (food service) = proved By
Date
❑ Planning Board (parking) = roved By
Date
® FIRE DISTRICT (I - II • II = Approved By Date
BUILDING DEPARTMENT APPROV
❑ ZONING
❑ BUILDING INSPECTOR/BUILDING CONIAIISSIONER
❑ CONTROL CONSTRUCTION AFFIDAVIT
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PROJECT SUMMARY:
new constructions alteration/demo
[Alter add interior walls] [add rooms] [add footprint]
sewage disposal - publiciprivate
[pool] [garageished/deck] [game court] food service]
Describe IAJ (tJ
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To the various departments:
water supply - publiciprivate well
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This notice has been forwarded to you for your information and any appropriate action. Should you have anv
questions please advise. If any reason to withhold the requested pe it is fo nd. pi vise. Your assistance.and
cooperation is appreciated. /
The Buildins Department - Date sent for review By
TOWN OF DARTMOUTH --BUI1bING`DE- PA [IT -AUNT'
TELEPHONE 508-999-0720 FAX> 508=999-0738
APPLICATION FOR ZONING AND BUILDING PERMIT
Ia>�nctions .
The applicant shall complete this application to the best of their ability prior to submission. leaving no item ®answered. The
Department staff will be available during regular business hours to assist as necessary. PUA should be inserted for those sections
which do not apply. A properly completed application will help avoid tmnecess=T delays. Nsrs ii9 fleein not -EFM
(for oMce we only) � ��Y
Total Cast s Received By Date Ree'd
Less Application Fee $
Total Permit Fee Permit # Cued Datt
100 LOCATION OF PROJECT
TOTAL LAND AREA SQUARE FEET
CURRENT ACCESSORS' PLAT M-'-'i LOT ZONING DISTRICT J
O ER ZONING OVERLAY DISTRICTS , if applicable
UMBER & STREET'
NEAREST CROSS STREET
SUBDIVISION NAME & LOT #
or BUSINESS NAME
PREVIOUS TEN OWNER ,/�dr l c
200 RESIDENTIAL - PROPOSED PROJECT - one & two family residence only
- THIS SECTION NOT APPLICABLE
= Single family number bedrooms number baths
= Two family - number bedrooms unit 1 number baths unit 1
number bedrooms unit 2 number baths unit 2
= Accessory apartment Total gross sq. ft.
= Accessory structure:
= Garage - detached - attached to dwelling, dimensions L W
_ Carport - detached - attached to dwelling, dimensions L W
= Shed - dimensions L W
= Deck - dimensions L W
- Gazebo - dimensions L W
_ Swimming pool above ground in -ground Size
_ Chimney - number of flues
- Woodstove - used (will require inspection prior to installation), new (provide manufacturers
instructions). Location(s) (list)
= Fireplace(s) - (includes flue) List location(s)
- Game Court - describe (include overall dimensions)
= Tent, Trailer (Mobile Home) or Other - describe
300 COMHffitCTAL - PROPOSED PROJECTIUSE - INCLUDING THREE FAMILY OR MORE AND EXEMPT USES
— THIS SECTION NOT APPLICABLE
(The following descriptions are based on the Massachusetts State Building Code Article 3, AS NOTED) (See the
Code)
The following section for official use only.
INSPECTORS' REVIEW
Date plan reviewed
30 days to review period expires
OK to issue date
_ OK to issue subject to requested submittals (see project review worksheet) date
DENIED see project review worksheet date
HOLD reason
date
HOLD Subject to Zoning Board of Appeals action
— Assembly - restaurant, lounge, theater, school, etc. (see Code Section 302.0) Describe
Comments
= Business - office, assembly with less than 50 occupants -indicate Medical or other professional (see Code Inspectors signature �blDate DEC 17 iggo
Section 303.0)
_ Educational -structure for training including child day care for those over Z years 9 months (see Code Section Applicant informed of above - Date time staff (fax, phone, in person)
304.0) ssi*iss#s##ssssssssi#sss!lss::ffssssssfssssss##!s##s##s##issss#ss#s#ss#sssss####ss#ssfssss!!s#sf:sss:ssss:
Over six months since approved for issue - DEEMED abandoned!
= Factory Industrial - (see Code Section 305.0) Advise applicant. Hold 90 days for return then dispose if not
PP P� picked up.
= High Hazard - (see Code Section 306.0)
_ Institutional - hospital, nursing home, infant day care (see Code Section 307.0) Inspector Date
_ Mercantile -retail stores (see Code 308.0)
Advised applicant Date Time staff (by phone, fax or in person)
= Residential - three or more family, hotel (see Code Section 309.0) OFFICEUNSPECTORS NOTES
= Storage - includes garages (see Code Section 309.0) TOTAL FEE C:3�2' v
= Utilitti• & Miscellaneous Structures - includes tents and agricultural structures (see Code Section 311.0) Gross area - new construction Total Sq. Ft.
_ \ew tenant for any of the above, indicate above (see Code Section 119.0 and Zoning By-law section 35) alteration Total Sq. Ft.
= Tent or Trailer • temporary purpose? Permit is issued to n� �L • c _ ��
_ Other
Describe the proposal briefly, INCLUDE-umberof dwelling units and bedrooms oroccupantbad as applicable, Comments/notes on permit
also existing condition
400 TYPE OF CONSTRUCTION OR WORK TO BE PERFORMED
= New Construction and/or Addition - total gross square feet
(For commercial only total gross cubic feet) - indicate
It will be considered new construction if there an increase in square footage in addition to anv
aiterationls).
If project is an addition to existing structure - Total gross square feet of existing
= FOR CONEWERCIAL ONLY
Will this project be subject to CONSTRUCTION CONTROL (over 35,000 cu.ft.) Yes �'o. (If yes
see Code section 127.0). Designer to submit Code Synopsis.
Will this project require Peer review (over 400.000 cu.ft.) Yes No (see Code .appendix I)
APPLICANT TO PROVIDE
1300 OWNER SIGN - OFF
- Alteration of existing, no increase in gross square feet. A separate Refuse Disposal Declaration required.
I, the undersigned, am the owner of record or authorized lessee (provide documentation) and I have reviewed
the application herein submitted. I state that to the best of my knowledge and belief that the information provided in this
application is true -and correct and that the permit requested be issued.
Further I understand that the permit will expire in six months, from the date of issue, if no work is begun or
six months after the last inspection if work has begun and'that the permit may be extended for six months if no work is
anticipated if I request such an extension in writing. I understand that the permit may be extended only three times by
written request. I understand that once the permit expires a new application may be required, including fees and current
other requirements (including Zoning).
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nature -
The above signs a is m voluntary act a' 'pis signed under the pains and penalties of perjury.
Date
Who is authorized to pickup the permit at the Building Department? /please orinn
Address Phone U
1400 HOMEOWNER EREl 11MON - ONE & TWO FAMILY ONLY
FOR HOME OWNERS 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 127.0, 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 accord2-ce with the rules and regulations promulgated by the BBRS enti!'ed
R:aes and Regulations for Licensing Construction Supervisors.
Exception: Any Home Owner performing work for which a Building Permit is required shall be exempt from
the provisions of this section; provides that if a Home Owner engages a person(s) for hire to do such work ,that such
Home Owner shall act as supervisor.
For the purposes of this sectior, 011iy9 a "Home Owner" 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
two-year period shall not be considered a Home Owner.
If you are applying under this section sign below:
Signature
Your signature ca es main respons ilities, including but not necessarily limited to, general liability
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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
2.15.2 of section 51
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1500 COST
Cost of Improvement
Items to be installed but not included in the above cost: Electrical S
Plumbing
HVAC
Other _>
TOTAL_'��'
= Demolition - describe structure
Number of dwelling units Number of bedrooms A separate Refuse Disposal
Declaration required.
Moving - (Provide copy of D.P.W. moving license) Type of structure -
from where (plat/lot or address)
to where (plat/lot or address)
Number of dwelling units Number of bedrooms per dwelling unit
- Re -roofing - (for existing only, is included in new construction)
Number of square feet
Number of layers when complete
A separate disposal declaration REQUIRED
Number of layers already existing
V/ Replacement doors and windows - (for existing only) (only where doors and windows exist and will not be
enlarged) EGRESS dimensions must be maintained. Enlarged or new windows in an existing dwelling will be
considered • an Alteration, herwise will be included in new construction. (see Code section 3401.10 for
residential and Ardcl- 8 ft.-- commercial)
Temporary structure - includes when allowed, trailers, tents and the like and only for limited periods of time.
.. :l. If.
Describe
.4
500 CONSTRUCTION PLANS Sf'(e r m elv_At
None submitted. Why? ZJr 1° �v� cQnc<��r,���X Si �l -Zx tf
= Submitted, usually three sets required. Four sets for food serviceluses. Number of sets submitted l
600 SITE PLAN
61
CY
Not required, why? � `-
= Submitted When? - Previously, date C With this application
700 UI'HMIES
Water supply - required — yes _ no, public ? _ yes _ no, on site well' _yes _ no,
existing? _ yes no
If required and not existing have necessary permits been issued? _ no _ yes, date
(M.G.L. Chapter 40, section 54 provides that no building permit may be issued unless a water supply, when
required, is available. See Code 780 CMR section 114.1.2)
Sewage disposal - required _ yes _ no, public sewer _, yes _ no
private septic - on -site _ ves — no. Submit copy of permit as soon as available.
800 MECHANICAI—S & PRIMARY FUEL
= 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
900 SPRINIMERS - FOR STRUCTURES OVER 7500 SQUARE FEET and certain multifamily residential
Required, --plans provided, plans not provided, why?
= Not required, not to be installed, Why?
1000 gEQUIRED OFF-%`TREST PARE3NG - for ZONING &Architectural Access
NOT APPLICABLE
= Parking Plan submitted To = Building Department ` Planning Board Date submitted
Number of spaces - indoors outside total provided
Handicap spaces - required _ yes _no. If yes, how many as a pirt of the total required number.
Is Route 6 (State Road) Entrance permit required? yes no If yes has it been issued yes - no 7.
Submit copy of application and/or permit as soon as available
1100 IDENTIFICATION (print or type except as noted)
nt owner -name
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7pnhhdress �J `Lni�y`% hi>.fy PWone
If corporation, officer in charge
Architect/Engineer - for overall design
Company name
Address
Phone number
Certified by State of Massachusetts as
Certification number
NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals and not
reproductions.
ArchihwtJEngmeer - project supervision and reports
Company name
Address
Phone number
Certified by State of Massachusetts as
Certification number
NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals and not
reproductions.
General Contractor 'f Homeowner state homeowner here then complete section 1300)
Compan,
Address
Phone number �Y r / 29Y
Construction Supervisors license number
NOTE Signatures and seals on all plans, affidavits and other documents SHALL BE originals and not
reproductions.
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1200 FOR RESIDENTIAL REMODEL WORK ONLY
Are you a Home Improvement Contractor subject to (780CMR - 6) ? Yes ,_ No _ If no go to next section! .
Are you claiming exemption from the requirement? Yes No _If yes, submit the required affidavit!
Ren_odel contractor name (please print)
Address
Registration number (it none state "none")
Phone number
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE
GUARANTEE 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
Date
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