BP-74123SECTION 12 - ESTIMATED CONSTRUCTION COST:,
Item Estimated Cost ($) to be completed by permit applicant
1, Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Off -Street Parking
6. Total = 0 + 2 + 3 + 4 + 5) Estimated Total Cost Including Labor. $ r
SECTION 13A - OWNER AUTHORIZATION '
{to`be'completed when owner's'agent'or contractor applies for building permit)
(Please Print)
1, '4�,r� e �J / ��� Ci as Owner of the subject property hereby authorize i?/YiC
to act on my behalf in all matters relative to work authorized by this building permit application.
Signature of Owner Date
...SECTION 1313OWNER/AUTHORIZED AGENT DECLARATION .
I (mil t 2 as Owner/Authorized Agent hereby declare that the statements and information
on the foregaolrrng application are true and accurate, to the best of my knowledge and belief.
Si P the pains and penalties of perjury.
Si nature o ner uthodzed Agent Date
SECTION 14-INSPECTOR'S REVIEW/COMMENTS
1. Date Plan Review:
2. 30 Days to Review Period Expires: ,n
3. OK to Issue Date:crdltcQ..
4. Per 750 CMR 111.1 Rejection Letter Sent:
5. HOLD - Reason: Date:
6. HOLD - Subject to Zoning Board of Appeals Action:
7. Comments:
8. Inspector's Signature: Date:
E O 15'- PPLICANT._N T F[CC//ATION
Applicant informed o �F: te: l Time: UI�IY Cler .
l)AComments: " `�
SECTION 16 -!OFFICE/INSPECTOR'S NOTES
p _ Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: $ �
Other $ Amount $
TOTAL FEE: Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
d
Permit Issued to: l �d �' 2- Q
Page 4
$25. 0 APPLICATION FEE IS NON RE•FIIl\TDPtIiLE NON-TIiL
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DARTMOUTH BUILDING DEPARTMENT T.
400 Slocum Road, P.O. Box 79399 20M AL -8 Hai q.10
Dartmouth, MA 02747
1664 Phone: 508-910-1820 Fax: 508-910-1838
www.town.dartmouth.ma.us
APPLICATION TOJQONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A COMMERCIAL BUILDING(including 3ormore family dwellings)
DEPARTMENTAL APPROVAL
Zoning Review:
Signature:
Energy Report:
Signature:
Fire Chief:
Signature:
Board of Health:
Signature:
Conservation Commission:
Signature:
Other:
Signature:
Brief description of work being performed.
Date: _
Date: _
Date:
Date:
Date:
Date:
1.1 NUMBER OF PLANS SUBMITTED: 1.2 SITE PLAN SUBMITTED: CTYes ❑ No
1.3 Property Address: L o ° ` Q 1.4 Assessors Map & Lot Number:
I l�%— Map —Ay—Lot
Nearest Cross Street: RoCX — D r— 2212 4:f
1.5 Water Supply (MGL c49 s54):
Business Name: ❑ Municipal [ I'Private Well
Business Phone #:
1.6 Sewage Disposal Sys
Total Land Area Sq. Feet: ❑ Municipal UrOn Site Disposal System
2.1 Owner Record:
w Y- I[
N me (print) Contact Address Phone Number
2.2 Authj'rized Agent:
d u7f � 9niP'� �t ny L/0 Loi�L��
Name (print) Contact Address Phone Number
Page 1 Revised 9/09
'SECTION 3 -CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable 0
Licensed Construction Supervisor: 076 5-3/
License Number:
Signature: Telephone:
SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT,
(MGL c- 152 § 25)
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this
affidavit will result in the denial Phe issuance of the building permit (MGL 152 Section 25A).
Signed Affidavit Attached: EYYes 0 No
SECTION 5 -DESCRIPTION 05 PROPOSED WORK (Check all applicable),
ci New Construction Ei Addition o Repairs o Accessory Building (Shed/Garage/Other)
Vother (Specify Sec. 6) Ei Demolition o Sign ii Replacement window'/door
No. of Windows Doors
[3 Fire Protection
SECTION 6 - PROPOSED PROJECT USE - INCLUDING THREE FAMILY OR MORE AND EXEMPT USES
The following descriptions are based on the Massachusetts State Building 7th Edition, Code Article 3, as noted. See the Code.
• Assembly - restaurant, lounge, theater, school, etc. (see Code Section 303.0)
• Business - office, assembly with less then 50 occupants - indicate Medical or other professional (see Code Section 304.00)
• Education - struction for training including child day care for those over 2 year 9 months (see Code Section 305.0)
• Factory/industrial (see Code Section 306.0)
• High Hazard (see Code Section 307.0)
• Institutional - hospital, nursing home, infant day care (see Code Section 308.0)
• Mdrcantile - retail stores (see Code Section 309.0)
• Residential - three or more family, hotel (see Code Section 310.0)
• Storage - including garage (see Code 311.0)
• Utility & Miscellaneous Structures - includes tents and agricultural structures (see Code Section 312.0)
• New Tenant - for any of the above, please indicate (see Code Section 110.0)
• Tent or Trailer - temporary
Describe the proposal, INCLUDE numbe g units and bedrooms or occupant load as applicable, also existing
condition (il extra space is needed, attach an additional sheet):
SECTION 7 TYPE OF CONSTRUCTION OR WORK TO BE PERFORMED
0 New construction and/or Additional (total gross cubic feet proposed) - indicate
If the project is an addition to existing structure - total gross square feet of existing:
0 Alteration of existing, no increase in gross square feet. A separate Refuse Disposal Declaration is required.
Will this project be subject to CONSTRUCTION CONTROL (over 35,000 cu. ft. 0 Yes 9140
If Yes, see Code Section 116.0 Designer to submit Code Synopsis in additional to original plans and if existing building Section 3402.1.1
Will this project require Peer Review (over 400,000 cu ft.) 0 Yes d'No (see 110. 11. 1 Code)
APPLICANT TO PROVIDE PEER REVIEW AT THEIR EXPENSE. SEE 780 CMR.
[I Demolition* - describe structure:
• Trench Permit Required? 0 Yes 0 No See Trench Requirements G.L.C. 82A and 520 CMR 7.00 et seq.
• Moving* - (provide copy of DPW moving license)
*Type of structure: from where (mapAot or address):
to where (mapAot or address): number of dwelling units:
number of bedrooms per dwelling unit:
0 Replacement doors and windows - (for existing only) (only where doors and windows exist and will not be enlarged)
EGRESS dimensions must be maintained.
[3 Temporary structure and uses - includes, when allowed, new tenants, trailers, tents and the like and only for limited periods of time.
8 MECHANICAL& 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):
El Air conditioning - (separate unit) Roof Top Unit (RTU) New El Replacement 0
• None of the above to be provided Mechanical Ventilation 0
• Hot Water: Gas Electric Fuel Oil Other
SECTION 9 -'SPRINKLERS AND/OR FIRE PROTECTION,'_:3 COPIES OF, PLANS AND NARRATIVE REQUIRED
• Required: plans provided plans not provided, why?
• Not required, not to be installed, why? Narrative Submitted? 0 Yes 0 No
10 - REQUIRED OFF-STREET PARKING (forZoning and Architectural Access)
0 Parking plan submitted to: Building Dept. _ Planning Board Date submitted
Number of spaces indoors outside Total provided
Handicap spaces - required Yes No if Yes, how many as a part of the total required number
Is Route 6 (State Road) entrance permit required? Yes No if Yes, has it been issued? Yes No
Submit copy of application and/or permit as soon as available.
11.1 Architect/Engineer - for overall design
Company Name:
Certified by State of Massachusetts as:
Certification Number:
Note: Signatures and seals on all plans, affidavits & other documents SHALL BE originals and not reproductions.
11.2 ArchitectlEngineer - project supervision and reports
Company Name:
Certified by State of Massachusetts as:
Certification Number:
Note: Signatures and seals on all plans, affidavits & other documents SHALL BE originals and not reproductions.
eneral Contractor
Construction Supervisors License Number: C-5 — 0 76,57 9
Note: Signatures and seals on all plans, affidavits & other documents SHALL BE originals and not reproductions.
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-FOUNDATION AND BASEMENT PLAN
SCALE 1'- 40" SCALE:
GATE:
APPROVED BY:
DRAWN BY
REVISED
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