BP-13989RESIDENTIAL
1999 RESIDENTIAL 0 FOUNDATION ONLY 1999
,.: :: 1 $25.00 APPLICATION FEE IS NON-REFUNDABLE
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: Date:
8. Comments:
9. Inspector's Signature:
Applicant informed of above Date:
Comments:
Time: Clerk:
Total Permit Fee: Less Application Fee: $ 25.00 Remaining Balance: $
TOTAL FEE: 3o. do Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued To•
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DARTMOUTH BUILDING DEPARTMENT DATE RECEIVED
ro _ 400 Slocum Road, P.O. Box 79399 �}
Dartmouth, MA 02747
'664 508-999-0720 FAX 508-999-0738
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Zoning Review: Signature:
Energy Report: Signatur .
Fire Chief: Signaa% re:
Board of Health: Sign4tnu e
A
Conservation Commission: Signature:
Other: Signature:
Description of work being performed:
Date:
Date:
Date:
Date:
Date:
Date:
1,
NUMBER OF PLANS SUBMITTED: i� SITE PLAN SUBMITTED: )�es
1.2 Assessors Plat & Lot Number:
1.1 Property Address: L,� A, 11 Plat . Lot -
Nearest Cross Street: ---A Co-,fNe,, A
Subdivision Name: _(,Shj ``\ �1.3 Historical District ❑ yes no
Total Land Area Sq. Ft.:.. 420 Has applicatio;7no en submitted to the Historic Commission?
Jm ��
0 yes Date:
1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System:
❑ Municipal 0 Private Well ❑ Municipal Lf On Site Disposal System
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RESIDENTIAL
I
1999 RESIDENTIAL
1999
2.1 Owner of Record:
Name (print)" (R`, K
2.2 Authorized Agent: �ux-
Name (print)
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor
Address
eS 4a`ecica� �3(r C1�81
Contact Address L.�vYI-iLrc ,� Yf% Phone Number
Contact Address
Signature Telephone
3.2 Registered Home Improvement Contractor:
Are you a Home Improvement Contractor subject to (780 CMR-6)? yee' s O no
If no, go to the next section!
Are you claiming exemption from the requirement? ❑ yes Ono
If yes, submit the
, nn required affidavit!
Company Name' f�j�/o(�p.��� ��L�l,,_.\ _k_oq
Addr-rss 1-�(l 2 C-iT V n r/I
Phone Number
Not Applicable
License Number
Expiration Date
Not Applicable ❑
Registration Number (if none, state "none")
Signature / Telephone G� 993-9 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
Date by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
5.4 Hom6okvnef Exemption -.One & Two Family Only
T 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 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:
r
Your
—LiMb umam responstmuties, 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 I
Supervisor, whether or not they have taken the permit are responsible for code compliance. (see Appendix of 780 CMR R5.2.15)
❑ 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 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:
Ta V-2 1 0 � ec -e- bulk L7- 417-v-,,,�7`?,
Item I Estimated Cost ($) to be completed by permit applicant I
15. Total = (I + 2 + 3 + 4) I * Estimated Total $ . - �v
lr��iii�i„ii�„
(please print)
13
1, Kkh : P , as Owner of the subject property hereby authorize %�\ -Qwt I 4CAh k6wniv
t my behalf' all matters relative to work authorized by this building permit apf liq ation.
V
Signature of wner Dat
I, , 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 under/afnns/n¢ penalties of
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Pate 2
Signature of Ownel(LAnthorized Agent
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Date
Rev. Jul 7, 1999