BP-49950Inspector's Signature:.
Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: $
Other $ Amount $
TOTAL FEE: /S O .O C Gross Area - New Construction total sq. ft. -7 % O S Fes_
Gross Area - Alteration total sq. ft.
Permit Issued to: - /J D r 7- rrj V C- A '7- C CC' •V Y � r'r /? R t S /l'
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❑ SPECIAL PERMIT (Per 780 CMR 111.13)
$25.00 APPLICATION FEE IS NON BE -FUNDABLE d NON-TUANSFEIIIABLE
-DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O. Box 79399 _
Dartmouth, MA 02747 -� a
Phone: 508-910-1820 Fax: 508-910-1838
64
www.town.dartmouth.ma.us
APPI icATinN TO CONSTRUCT. REPAIR. RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
ergy Report: Signature: Date:
e Chief: Signature: Date:
and of Health: Signature: Date:
mservation Commission: Signature: Date:
her: Signature: Date:
1.1 Property Address: f7r hf� t/►'� 1.2 Assessors Map & Lot Number:
Nearest Cross Street: ( V / Y Map 1 Lot -
Subdivision Name:
1.3 Historical District ❑ Yes>(No
Total Land Area Sq. Feet: Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
1.4 Water Supply (MGL 0 s54): 1.5 Sewage Disposal System:
❑ Municipal Private Well ❑ Municipal �On Site Disposal System
CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
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RESIDENTIAL
SECTION 2 - PROPERTY` OWNERS
/AUTHORIZED` AGENT
2.1 Owner ord:
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Ir
-158
Name (pr nt)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
:, .. SECTION.3 -CONSTRUCTION SERVICES -.:,'
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor:
License Number:
Address:
Expiration Date:
Signature: Telephone:
3.2 Registered Home Improvement 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 claming exemption from the requirements? ❑ 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
❑ ' am a Homeowner erforming all the myself.
(work
Ow ers Name (print):
ignature:
B signing the above, the homeowner acknowledges that there will be no eligibility 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 person(s) for hire to do such work, that such Homeowner shall act as supervisor.
For 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
a purposes
;01the 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
17 e home in a two-year period shall not be considered a Homeowner.
If you are applying underthis sectio sign below:
Signature:
Your ignat a carries certain responsibilities, including but not necessarily limited to, general liability
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed 5 onstructic
k th ermit are responsible for code compliance. (see Appendix of 780 CMR R5 )
Supervisor, whether or not they have to en e p
6 ,152 25 ,... F DAVIT MGL )
>_SECTION 4 -:WORKER S COMPENSATION AF I ( §
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: ❑ Yes ❑ No
77
Deck ❑Pooh ❑Repairs ❑Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Specify below)
(Energy report required) (Shed/Garage)
❑ Addition ❑ Replacement window/door ❑Demolition
(Energy report required) No. of windows Doors _ (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
❑ 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
Description of proposed work: 02
Item
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC;
5. Total = (1 + 2 + 3 +
(Please Print)
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to act on my behalf, in all matters relative to
Signature of Owner
Estimated Cost ($) to be
Owner of the subject property hereby authorize
-I-
rized by this building permit application.
Date
I Cc as Owner/Authorized Agent hereby declare that the statements and information
on the foroy8ing application are true and accurate, to the best of my knowledge and belief.
Signed and pains realties of perjury.
- ^ ---• Date
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I CERTIFY THAT THIS PLAN WAS PREPARED
IN ACCORDANCE WITH THE RULES AND
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.IVA TTTR / DATE
JUNE 8 2004
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I CERTIFY THAT THIS PLAN WAS PREPARED
IN ACCORDANCE WITH THE RULES AND
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AN %tS 'HE RESULT OF AN ACTUAL FIELD SURVEY.
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�S GNATUR DATE
JUNE 8 2004