BP-10701Residential
13 FOUNDATION ONLY
DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O. Box 79399 }
\3o Dartmouth, MA 02747 1 f^:� T
508-999-0720 FAX 508-999-0738 , �' 16
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
1999
Zoning Review:
Signature:
Date:
Energy Report:
Signature:
Date:
Fire Chief.
Signature:
Date:
Board of Health:
Signature:
Date:
Conservation Cormission:
Signature:
Date: _
Other:
Signature:
Date:
NUMBER OF PLANS SUBMITTED: 3 SITE PLAN SUBMITTED: 0-yes ❑ no
1.1 Property Address: 1.2 Assessors Plat & Lot Number:
Nearest Cross Street: k v �� Ra • Plat Z 41 Lot
Subdivision Name: 1.3 Historical District ❑ yes Erno
Has application been submitted to the Historic Commission?
Total Land Area Sq. Ft.: ❑ yes 0 no Date:
ater Supply (MGL c 40 § 54):
0 MunicipalZPrivate Well
_VS 011�\Z)jw (� �t
Name (print)
❑ Municipal t On Site Disposal System
Contact Address
phone number
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Residential
1999 Residential
2.2 Authonzed Agent:
R04�r,�A \11AW-1
Contact Address
Name (print)
Telephone
t._.::.:. t`.....:RV S�Q
......
3.1 Licensed Co stru io�n u ervisor:
v
0 f�tv �oc:�
Not Applicable ❑
Licensed ConstQtiioon Supervisor
License Number to 1 2
cJ
Address
psor
Ex [ration Date
C.— �SignatureTelephone
Signature
3.2 Registered Home lm ovement Contractor:
Not Applicable ❑
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
Registration Number (if none, state "none")
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 rint).� fl
•.">ignature
by signing the above, tht home ot�mer a knowledges that there will be no elieibilty to the Guaranty Fund
Date C
—l�/
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 Super-zsors: 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:
Signature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
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
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: dyes ❑ no
-new ❑ addition ❑ alteration ❑ repairs
construction*
❑ chimney/fireplace
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other
(shed/garage) no. of windows_ doors_ (specify below)
* If new construction, please complete the following• 7 I
Single Family: no. of bedrooms no. of bathsZ—
Two Family: no. of bedrooms unit 1 no. of baths unit 1
no. of bedrooms unit 7 no. of baths unit 2
Brief Description of Proposed Work:
❑ woodstove
❑ demolition
(specify below):
Item I Estimated Cost ($) to be completed by permit applicant
..--uuts
z66 00
2. Electrical 7, 0 C) a
4.
= ( I + 2 + 3 +
* Estimated Total
Signed under the pains and penalties of perjury.
V111, do 5
of Owner/Authorih"d- Agent
$ Z (p/Uaa
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