BP-34043RESIDENTIAL o 2004
FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE Af WnW_TRj%Wcrruaurs
RESID 2004
❑ FOUNDATION ONLY
$25.00 PLICATION FEE IS NON-REFUNDABL= ", -o - NSFERABLE
ARTMOUTH BUILDING DEPARTMENT
y' 400 Slocum Road, P.O. Box 79399 11M MAI 25 P. 3: 40
•}�'jhho ,5y�' Dartmouth, MA 02747
_..�
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Zoning Review:
Energy Report:
Fire Chief:
Board of Health:
Conservation Commission:
Other:
Signature: Date:
Signature: Date:
Signature: Date:
Signature: Date:
Signature:
Description of work being performed:
OF PLANS SUBMITTED:
1.1 Property Address: w /nd' �% \
Nearest Cross Street:�f,��p� creme �c��l�
Subdivision Name: \,J\iN1ks-
T,otal Land Area Sq. Ft.:���
� J
1.4 Water Supply (MGL c 40 § 54):
❑ Municipal Y4vate Well
SITE PLAN SUBMITTED:
❑ no
1.2 Assessors Plat & Lot Number:
Plat... Loth
-_L-
1.3 Historical District ❑ yes 2"no
Has application been submitted to the Historic Commission?
❑ yes ❑ no Date:
Sewage Disposal System:
❑ Municipal e n Site Disposal System
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Page 1
Rev. January 1, 2003
IDENTIAL
v
2.1 Owner of Record: • r
Name
Authorized Agent:
LI 5(r,
Name (print)
3.1 Licensed Construction
Licensed Construction Supervisor
Address
2004
Contact AddreM Phone Number
Contact Address Phone Number
Signaturif e — �C1 fn � >> Lj,, Telephone 6Z
3.2 Registered HodK Improvement
Are you a Home Improvement Contractor subject to (780 CMR-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
Address
Signature Telephone
3.3 For Residential Remodel Work Only
Not Applicable ❑
License Number JO
Expiration Date
Not Applicable ❑
aC/ -6 v
Registration Number (if none, state ❑ none❑)
Expiration Date
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) N C�
Signature
by signing the bove, qie home ner acknowledges there will be no eligibilty to the Guaranty Fund
Date � �a< It�la
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 individualing the structural elements of
shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involv
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 wide, on
which there is, or is intended to be, a one or two family dwelline, attached or detached structures accessory to such use and/or farm structures. A person o 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:
carries
mcmaing but not necessarily limited to, general liability
RESIDENTIAL 2004
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)
EC�c�Qv wt�x7 nvTcNNsINI FAVrTzI c}
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit
will result in the denial the issuance of the building permit. Signed Affidavit Attached: ❑ yes ❑ no
❑ new construction*
(energy report requul ed)
❑ deck 'pool
❑ addition
(energy report required)
❑ alteration ❑ repairs ❑ chimney/
fireplace
❑ accessory bldg.
❑ replacement window/door ❑ other
(shed/garage)
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 (specify):
❑ Air conditioning - (separate unit)
❑ None of the above to be provided.
❑ Hot Water: Gas Electric Fuel Oil Other
Brief Description of Proposed Work: ` N
Item
5.Total =(1+2+3+4)
kPlease print)
Estimated Cost ($) to be completed by permit applicant
* Estimated Total $
I'---
' , as Owner of the subject property hereby authorize
to act on y behalf, in a matters relay e to work authorized by this building permit app ica Ion.
Signature of O ner
Date
❑ woodstove
❑ demolition
(specify below):
UK\ , as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing placation are e and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
l
Signature
Agent
Date
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