BP-10299Residential
1999
Residential
�F'OUNDATION ONLY
1999
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:
8. Comments:
9. Inspector's
Applicant informed of above
Comments:
Date- Time: Clerk*
Total Permit Fee: $ 5 0 o I Less Application Fee: $ 25.00 I Remaining Balance: $ e"1)3
TOTAL FEE:
Permit Issued
Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
A)&_,40 'k
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�PMpUTy;9�;t DARTMOUTH BUILDING DEPARTMENT DATE RECEIVED -
(f 400 Slocum Road, P.O. Box 79399
o x;
�,. 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:
Dater
Energy Report:
Signature:
Date:
Fire Chief:
Signature:
Date:
Board of Health:
Signature:
Date:
Conservation Commission:
Signature:
Date:
Other:
Signature:
Date:
NUMBER OF PLANS SUBMITTED:
t. i rroperry Haaress�U / I%Z0c_A (Z�, ,
Nearest Cross Street:���Qv��`��
Subdivision Name:
Total Land Area Sq. Ft.: U is
ater Supply (MGL c 40 § 54):
❑ Municipal❑ Private Well
�R� �A w� �OA)A
l
SITE PLAN SUBMITTED:
1.2 Assessors Plat & Lc
❑ yes *no
Lot .
rttstoncat litsmci u yes dn�no
Has application been submitted to the Historic Commission?
❑ yes ❑ no Date:
1.5 Sewage
❑ Municipal 13,0n Site Disposal System '!
Contact Address r� 990 _0 037
A, phone number
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Residential 1999 Residential 1999
2.2 Authorized Agent:
Contact Address ^
Name (print)
Telephone
»:;u ::;;:::;:::;:>:>;:::::.::::Ei S..'Sltt��`�t#�1�.,�`l~'lt�t+>r�`�"'::<
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31 L 1 ction P ervisor::_:`:::_-:::
Not Applicable
6F19:JVA C.,1
Licensed Construction upervi r \
V
License Number -1 Q,
Address }� �? t O
Expiration Date
Signa a Tel hone
�ad
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? 1414es ❑ no
If no, go to the next section!
Are you claiming exemption from the requirement? ❑ yesZno
If yes, submit the required
(- affidavit!
+�• Vk�
Company Name
Registration Number (if none, state `hone")
Address
Signature Telephone
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
by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
Date
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 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 ybu are applying under this section sign below:
Signature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
c:\wpwin\forms\bldgapp.res Page 2 January 20, 1999 ,
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)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit t
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes ❑ no
new ❑ addition ❑ alteration ❑ repairs ❑ chimney/fireplace. ❑ woodstove
construction*
❑ 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
Brief Description of Proposed Work: f� v ►J C�� 10 J.) (�11 U
Item I IEstimated Cost ($) to be completed by permit applicant
•r 1. Building —ov . k ; o la 64 Q
1t�
=0+
(plea§e print)
on
of Owner
* Estimated Total
as Owner of the subject property hereby authorize
to work authorized by this building permit application
�i
blZe
I, VAl -o (_5 , 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.
pains and penalties of perjury.
,"'iR�-.6tn
ame
Signature of Owner/Aufho%raed Agent
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Date
GV
January 20, 1999