BP-11527Residential `, J% ;7 A,- --
Residential
❑ 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: Date'
7. HOLD subject to Zoning Board of Appeals action:
S. Comments:
9. Inspector's Signature: Date:
Applicant informed of above /Date- 6-0 i 4f - 9R Time: to Clerk
Comments: Q / �" /,/"7Z,,
6e�st Zel<� 701
Total Permit Fee: $ I Less Application Fee: $ 25.00 I Remaining Balance: $ '4!b l%, e%) !
TONAL. FEE: Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued Tom �T
;0 DARTMOUTH BUILDING DEPARTMENT _ DATERECEIVED
400 Slocum Road P.O. Box 79399 F1•
o _ Y"`. Dartmouth, MA 02747 -,•� r
Iii, ;i 1�1 l� 15
508-999-0720 FAX 508-999-0738
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Zoning Review:
Signature:
Date:
Energy Report:
Signature:
Date:
Fire Chie •
Signature:
Date:
oard of Health:
Signature: J^4
Date: (why T
Conservation Commission:
Signature:
D te:
��
(� p) g �Ad te:
NUMBER OF PLANS SUBMITTED: NO SITE PLAN SUBMITTED: E yes ❑ no
1.1 Property Address: �t .-Y :�" e-, 1.2 Assessors Plat & Lot Number:
Nearest Cross Street: _—h►, r u '(0t�a. 0 Plat Lot 4Lf _-
Subdivision Name: 1.3 Historical District ❑ yes to
Has application been submitted to the Historic Commission?
Total Land Area Sq. Ft.: �r` ��%G.s ❑ yes no Date:
1.4 Water Supply (MGL c 40 § 54 : %f 1.5 Sewage Disposal System: /'
['Municipal❑ Private Well ❑ Municipal n<n Site Disposal System i
Contact Address
40 Name (print) � V �"T
phone number
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Residential
IQQQ
2.2 Authorized Agent:
Contact Address
Name (print)
Telephone
rc;trr.sl l e s.............>::.:::.::::;;::.::::::::::.:::.......................................:;
3lle
Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor
License Number
Address
Expiration Date
Signature T h e
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to ( 80 MR-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 (ifnone, state "none")
Address
Signature Telephone
Expiration Date
3.3 For Residential Remodel Work Only
i
PERSONS CONTRACTING UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY
FUND: QUESTIONS OR CO S call or write:
Home Improvement Contract 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 A
structures. 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: t
Your sign re ies certain res`sibilities, including but not necessarily limited to, general liability
Residential
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)
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: X yes ❑ no
❑ new ❑ addition ❑ alteration
❑ repairs
❑ chimney/fireplace
❑ woodstove
construction*
❑ deck pool ❑ accessory bldg.
❑ replacement window/door
G/YIOyL.��
�J o er
❑ 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 1-no.
of baths unit 1
no. of bedrooms unit 2
no. of baths unit 2
Brief Description of Proposed Work:
i -.,-` - - -4 1. w f. (
Item I Estimated Cost ($) to be completed by permit applicant
1 1.
.s. riumomg
4. Mechanical (HVAC)
5.Total =(1+2+3+,
* Estimated Total
$ M1 J300
(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
as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing apylication. are truand accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
e
Print Name VIV
Signature of Owner/Aut rite gent k, VZ.001
Date
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