BP-25932SECTION 8 - INSPECTOij,'S REVIEW/COMMENTS
,
I. 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):_
5. DENIED (see project review worksheet):
6. HOLD reason:
7. HOLD subject to Zoning Board of Appeals action:
8. Comments:
9. Inspector's Signature:
JV SECTION 9 - A P CANT NOTIFICATION
Applicant inform d of Bove Date: 02
Time/�
Comments:
SECTION 10- OFFICEVNSPECTOR'S NOTES
Total Permit Fee: $ I Less Application Fee: $ 25.0__ 0
TOTAL FEE: Gross Area - New Construction total sq. ft.
�/`/ Gross Area - Alteration total sq. ft.
Permit Issued ToC, X 9? e�A
Clerk:
Remaining Balance: $
SECTION 11 -ADDITIONAL COMMENTS/SKETCHES
2001
Date:
Date _
Date.
RESIDENTIAL
❑ FOUNDATYN ONLY ./ 1
$25.00 APPLICATION FEE IS NON-RErUNDABLE do NON -TRANSFERABLE
� DARTMOUTH BUILDING DEPARTMENT 7 `?DATE RECEIVED
n,
400 Slocum Road, P.O. Box 79399
Dartmouth, MA 02747
/664 :�� 508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY: BUILDING PERMIT
DATE SENT FOR REVIEW: Z
NUMBER:_„2 rG%✓�
DATE ISSUED:�--
OK TO ISSUE -'SIGNATURE:
Building Commissioner/Insp r of Buildings DATE
ZoningS� ,
District: roposed Use: „� Zone: ❑ B ❑ A ❑ V Outside Flood Zone ❑ Aquifer Zone
THE FOLLOWING A NCIES SRO D BE NOTIFIED:
Board of ❑ oard of on. Com. ❑Demo ❑DPW
ppeals alt ❑ Elec. ❑ Energy Report
Affidavit 'Card Sent Cut Off Follow-up*
V
❑ Fire ❑Gas Review
Chief Cut Off ❑ Planning Board* ❑ Sewer Card ❑ Water Card `
/Cut Off /Cut Off ` ❑ Zoning ❑Other _
* REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPARTMENTAL APPROVAL
Zoning Review:
Energy Report:
Fire Chief: -"j-�
1
Board of Health:
Conservation Commission
Other:
Signature: _
Date:
Signature:
Date:
Signature: -
Date: 0<
Signature:
Date: / 4?.
Signature:
Date: 9 ; D Z
Signature:
Date:
Description of work being performed: 0 J�C�( _ , n/i
SECTION 1- SITE INFORMAT
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED' ❑
1.1 Property Address:-2- ''SEI10j [� l( �_
Nearest Cross Street: `_,� rcC (k�
Subdivision Name:
Total Land Area Sq. Ft.: 30 UO b S�
1.4 Water Supply (MGL c 40 § 54):
❑ Municipals Private Well
yes
1.2 Assessors Plat & Lot Number:
Plat ZZ Lot_
❑ no
1.3 Historical District ❑ yes /N(no 1
Has application been submitted to the Historic Commission?
❑ yes ❑ no Date:
1.5 Sewage Disposal System: o
❑ Municipal 2 0n Site Disposal System
C:\bldg. forms\B Idgapp.res.wpd
Page 4
Rev. January 19, 2001
C:\b1dg-fornns\B1dgapp.res.wpd
Page I
1%-Uj131L1-1AN I IAL 2001
SECTION 2 — P ROPERTY OMMRSMP A ITTHORIZED AGENT
2.1 Owner of Record:
TnI"—, -
I Atu- W—. 4-�(O-qe2l
Name (print) Contact Address Phone Number
� f -/� tVA- C.,ew fN C
Name (print)
6-� r2 sS4�-6 p c( �C c 0 0
Contact Address Phone Number
c uvi� - �utv�7'R CTION S
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor-?�M(*rW --fFC>6:n,6(LA—
Address P-(QeVW 4--zW A,�,
01g't1QLUr, Telephone qJ)3
3.2 Registered Home Improvement Contractor:
Are you a Home Improvement Contractor subject to (780 CMR-6)? 0-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.t ��t� L CG1tiJ� 1 �� C—
Address
Signa Telephone 9�6 LM-6
Not Applicable ❑
License Number Q3-9-
Expiration Date
Not Applicable ❑
Registration Number (if none, state "none")
Expiration Date
3.3 For 1�r6dential 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, AfA 02108, (617) 727-8598
Owners Name (print)
1.
Signature
Date by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR 01;k N 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:
Sienature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
RESIDENTIAL
2001
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)
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL c 152 § 25)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failu to provide this affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: D es ❑ no
SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable)
❑ new construction* addition ❑ alteration ❑ repairs ❑ chimney/ ❑ woodstove
(energy report required) (energy report required) fireplace
❑ 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 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 (specify):_
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Brief Description of Proposed Work.
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost ($) to be completed by permit applicant
/)\Z/
5. Total = (1 + 2 + 3 + 4) ZV r— I "Estimated Total $ ;,?&
SECTION 7A — OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(please ,dint)
1, e- , as Owner of the subject property hereby authorizet�
to ac n beha , in att�relat�ivetoork authorized by this building permit application. I
Signatur f Owner
Date t
t (� C , 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 th ains and penalties of perjury.
of Owner/Authorized Agent
Date
C:\bldg.forms\Bldgapp.res.wpd Page 2
Rev. January 19, 2001
C:\bldg. forms\B Idgapp.res.wpd
Page 3 Rev. January 19, 2001