BP-59102SECTION 8 - INSPECTOR'S RE%AMICOMMENTS
]AN 1 12010
1. Date plan reviewed:
2. DENIED (see project review worksheet):
Date:
3. HOLD
Date:
Reason:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Inspector's Signature:
Applicant informed
I Comments:
Total Permit Fee: $
TOTAL FEE:.
Permit Issued to:
'71'
r N
ma,mma",
1
Less Application Fee: $25.00
Other $ Amount $
Gross Area - New Construction total sq. ft
Gross Area - Alteration total sq. ft.
Date: JAN 1 12010
Remaining Balance: $
RESIDENTIAL ❑ Approval in Part (Per 780 CMR.5111.13)'
�nr nn aVDWDW WIVA"mW m wwu we 1wam RF:iPum IAR1LF. & NON -TRANSFERABLE
DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT RECEIVED
° 400 Slocum Road, P.O. Box 79399 AR7 10i i` ! r- f (.PEPT.
z Dartmouth, MA 02747
�664 ; Phone: 508-910-1820 Fax: 508-910-1838 M DEC 30 AM 9: 22
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
Zoning Review: Signature: �[�, ��+ T7�- Date: JAN 112010
Energy Report: Signature: Date:
Fire Chief. Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other: Signature: ,( Date:
Brief description of work being performed• K( `OLA-b
1.4 Water Supply (MGL c40 s54):
❑ Municipal k Private Well
1.5 Sewage Disposal System:
❑ Municipal $ On Site Disposal System
CONSTRUCTION PLANS
❑SITE PLAN ❑ENERGY REPORT
RESIDEM 1
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner Record:
JOAn/TA-RH&q 367 Rocf<-o-Da-vve6k SOB-99y�`f663
Name (print) Contact Address Phone Number
2.2 Authorized Agent:
1511 TOrA4 379' Ro. S6b-992-?Z4
Name (print) Contact Address Phone Number
SECTION 3 = CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Y6s Not Applicable ❑
t� Licensed Construction Supervisor: V/141 %% /KOT License Number: C5 68� t g
Address: 3?Q 4
Expiration Date:
wSignature: Telephone: s09- Tfa-71S k
V3.2 Registered Home Improvement Contractor: yes Rorg Not Applicable ❑
S. Are you a Home Improvement Contractor subject to (780 CMR.1 I O.R6)? j(Yes ❑ No
S. If No, go to the next section!
OAre you claming exemption from the requirements? ❑ Yes kNo
V If Yes, submit the required affidavit!
Company Name: AOV44s R Registration Number (if none, state "none"):
Address: 3xt Rozlc•4•,a,�, R l a73 a7
Signature: Telephone: Expiration Date: 1� Q 4010
3.3 For Residential Remodel Work Only
PERSONS C CTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS UARANTY FUND:
QUESTIONS OR COMP II or write:
Home Improvement Contra cto ration, One Ashburton - Room 1301, Boston, MA 02108, 617-727-8598
❑ 1 am a Homeowner performing all the work
Owners Name (print):
Signature:
By signing the above, the homeowner acknowledges that there will be no eligibilityto the Guaranty Fund
Date:
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN
5108.3.5 Licensing o struction Supervisors: Except for those structures governed by Construction Control in Secti . , effective July 1, 19 individual
shall be engaged in directly supervi ' ersons engaged in construction, reconstruction, alteration, repair, re r demolition involving the structural elements of buildings
or structures, unless he or she is licensed in rdance with the rules and regulations promulgat a BBRS entitled Rules and Regulations for Licensing Construction
Supervisors.
Exception: Any Homeowner performing work for which a Permit ir�ll 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 Homeo ct as supervisor.
For the purposes of this section only, a "Homeowner' * fined as follows: 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 twos a ling, attached or detached structure ssory to such use and/or farm structures. A person who constructs more than
one home in a two-year period considered a Homeowner.
If you are a` yi/ng under this section sign below:
Signature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
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 of the issuance of the building permit. Signed Affidavit Attached: XYes ❑ No
SECTION 5 1 DESCRIPTION OF PROPOSED WORK (Check all applicable)
❑ Deck ❑ Pool ❑ Repairs OrAlteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage) (Specify below)
❑ Addition WReplacement window/door ❑ Demolition
(Energy report required) No. of windows I Doors (Specify below)
*If new construction, please complete the following: /,,0,
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
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
DescriptionG of proposed work: Rb&gc&i&d ce 4o4*,4 'oo— -iA s;,/,- side tA*4 R�r,V/ of 3-0 r6-61
Rat c-, 06e W,fA C'o"1% R G(%Oiwar R iA/t�0i1vQ'_ R/6'N/ AY10 /40p /v rhov1� �i�rv� C4,.Ve
SECTION 6 'ESTIMATED CONSTRUCTION COST
Item Estimated Cost ($) to be completed by permit applicant
1. Building SiaaO•ee
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = M + 2 + 3 + 4) S, 060,00
(Please Print)
1, Job A �%lt2 ���e� , as Owner of the subject property hereby authorize ,61//
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 713- OWNERIAUTHORIZED AGENT_ DECLARATION
7,eoz4/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 the pains and penalties of perjury.
Signature of
Agent
Date
/2--,z9'-09,