BP-63345SECTION 8 - INSPECTOR'S REVIEW/COMMENTS " RESIDENTIAL
❑ Approval in Part (Per 780 CMR.5111.13)
plan reviewed: JUI� 2��� $25.00 APPLICATION FEE IS NON HE-FU"ABL1, & NON-TRANSFER"L1E
1. Date p _ DATE RECE�FVED
2. DENIED (see project review worksheet): i ��°"T"' *• Date: DARTMOUTH BUILDING DEPARTMENT
� .,� ,.�`°� ."N`_
B
P.O.
400 Slocum Road, Box 79399
3. HOLD D
_-
° _ Dartmouth, MA 02747
Reason:
' /,� � p ate:. z _�� _ �'
/!✓ Uj"`�� �o y,.
4. HOLD subject to Zoning Board of Appeals action: Date: -•.�_ . SY: Phone; 508-910-1820 Fax: 508-910-1838
+.- lfifi4 ��
www.town.dartmouth.ma.us
Comments:
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTICI OR OFFICIAL USE ONLY .,
RFrFIVED'R4.
BUILDING PERMITNUBR
e=s-'
Inspector's Signature:
=:SE TIO -.APPLICANT. NOTIFICATION :.
Applicant informed of above: Date: 1-71W
Time:
PP
Comments:
SECTION 10= OFFICE/INSPECTOR'S NOTES
Less Application Fee: $25.00
Total Permit Fee: $
Other $ Amount $
TOTAL FEE: 75 Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:.
1 ADDITIONAL COMMENTS/SKETCHES .
I
JUN 0 3 21311
Date:
'rgy Report: Signature
Chief- Signature:
and of Health: Signature:
nservation Commission: Signature:
Date: ju1st_ZIA 9L
Date:
Date:
Date:
Other. Signature: uate:
Brief description of work being performed:
SECTION 1 _-°77777-777777-
SITE INFORMATION ; "'
1.1 Property Address: LAPNAM 10VLSE 1.2 Assessors Map & Lot Number:
Ma
Lot Area (sf.) Frontage p
Required Provided
Front Yard 1.3 Historical District ❑ Yes XNo
Side Yard Has application been submitted to the Historic Commission?
Rear Yard a ❑ Yes ❑ No Dater
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal VPrivate Well ❑ Municipal Xon Site Disposal System
CONSTRUCTION PLANS... El SITE PLAN
❑ ENERGY REPORT
RESIDENTS
SECTION:2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner Record:
Clfvoy f co��3iiv I�c?�/�Y - 3 4APAMI '�G9w� SOS-IC19-cril
Name (print) Contact Address Phone Number
2.2 Authorized Agent:
V/dlmm 7-ox 3,7g Rock-a100,vaex R0, s�8��79-,7;tss
Name (print) Contact Address Phone Number
SECTION*3, :CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: e
Licensed Construction Supervisor: L/diiAM i%* 1QC-X4k License Number:
Address: 37q got&-0- ci-M,4c ka �:I�a:(,V& � P?A Oa448 Expiration Date: f-as- to13
Signature: 6 ��%� Telephone: 508 ^qCf JJ- �E-AS
3.2 Registered Home Improvement Contractor: Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMRA 10.R6)? ' Yes ❑ No
If No, go to the next section!
Are you claming exemption from the requirements? ❑ Yes X No
If Yes, submit the required affidavit!
Company Name: -ftxn U-S 2F Registration Number (if none, state "none"):
Address: 379 E1�/c-d (�v.+unEF �, S� i���3'�"it" f% C3A,7
Signature: e� Telephone: SO'R 991-fxk;14 Expiration Date: fa'1�-
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 Re istration ' One Ashburton - -
p g urton Place Room 13111, os--$ ton, MA 02108, 617-727 8598
❑ I am a.Homeowner performing all the work myself.
Owners Name (print): _
Signature:
By signing the above, the homeowner acknowledges that there will be no eligibility to the Guaranty Fund
Dale
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN �P CT
5108.3.5 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.o if vedEi a July 1, 1982, no individual " "
shall be. engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demo "' 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 nfttfVd Ru tes and Regulations for Licensing Construction
Supervisors.
Exception: Any Homeowner performing work for which a Building Permit is required shall be mpt 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 super .r.
For the purposes of this section only, a "Homeowner" is defined as fo lows- Person(.) 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 dwellir►g, attachet or 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�meowner.
If you are applying and s 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)
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: Wyes ❑ No
_ 'SECTION 5 =.DESCRIPTION OF PROPOSED WORK (Check all 'applicable)
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. Roofing/Siding ❑ Other
(Energy re required) (Shed/Garage) (Specify below)
9Y report
❑ Addition ❑ Replacement window/door ❑ Demolition
(Energy report required) No. of windows _ Doors _ (Specify below)
*If new construction, please complete the following`-
ka
Single Family: No. of Bedrooms No: of Baths
1
Two Family: No of Bedrooms Unit 1 Noci Baths Unit 1 •
No of Bedrooms Unit 2 -- No. of Baths Unit 2
❑ Furnace (hot air) - fuel gas (natural or propane),.fa€f oil, electricity, other (specify):
❑ Boiler (heating) - fuel gas (natural o ane), fuel oil, electricity, other (specify):
❑ HVAC (combined unit)- ary fuel, natural gas, propane, electricity, other
❑ Air conditio ' -separate unit)
❑ No the above to be provided
of Water. Gas Electric fuel Oil Other
Description of proposed work:+5u,4-'r
C40 614c
SECTION 6. ="ESTIMATED CONSTRUCTION:COST
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
ov0
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = (1 + 2 + 3 + 4)
SECTION 7A.-OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(Please Print)
as Owner of the subject property hereby authorize A/� 7ke-7-4'
to act o 'be alf, in all matt r r lative to work authorized by this building permit application.
/V V/-C,
Signature of Owner Date
= SECTION 7B = OWNERIAUTHORIZED AGENT DECLARATION
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 Owner/Authorized Agent Date