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BP-22424RESIDENTIAL 2001 SECTION 8 - INSPECTOR'S REVIEW/COMMENTS 1. Date plan reviewed: % — a -7 — Q 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: Date: 8. Comments: 9. Inspector's Signature: Date: SECTION 9 - P C T NOTIFICATION Applicant informed of bov Date: Time: Clerk: Comments: SECTION 10- OFFICEVNSPECTOR'S NOTES _ Total Permit Fee: $ Less Application Fee: $ 25.00 Remaining Balance: $ TOTAL FEE: _ Gross Area - New Construction total sq. ft. Gross Ar - Alteration total sq. ft. Permit Issued To- 19 - f7w, SECTION -"ADDITIONAL f r SIDENTIAL 2001 ❑ FOUNDATION ONLY $25.00 APPLICATION FEE IS NON.REFUNDABLE do NON -TRANSFERABLE DARTMOUTH BUILDING DEPARTMENT DATE RECEIVED 400 Slocum Road, P.O. Box 79399 Dartmouth, MA 02747 508-910-1820 FAX 508-910-1838 APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING THIS SECTION FOR OFFICIAL USE ONLY - - � t - _ - _ ..; RECEIVED BY: ,... �;; �t fiY' Y r? Fin !.-F{.• T , •_ ) BUILDING PERMIT ` -<Pi 4 at DATE SENT FOR REVIEW: =. t NUMBER DATE ISSUED:,! . OK TO ISSUE - SIGNATURE.DATE :. Building mnussionert spector o Idings oposed Use:- • Zoning District:lebpr .G. B ❑ A❑ V ❑o,d� n�tte�l, - !- THE FOLLOWING AGENCIES SHOULD BE NOTIFIED t 'I - x, .t,., R�cL ❑ Board of ❑Board of ❑Con Com ❑Demo DPW ❑ ❑,Elec .'❑ Energy lieport pp Health A eats - Affidavit *'` Card Sent Cut-Off:_Follow up ❑ Fire ❑Gas ❑Planning Board* . ewer Card 17 Water Card ❑ Zoning Other Chief Cut Off / Cut Off / cutoff Review* V r ;� t * REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.; DEPARTMENTAL APPROVAL Zoning Review: Signature: Date: Energy Report: Signature: Date: Fire Chief- Signature: Date: Board of Health: Signature: Date: Conservation Commission: Signature: Date: Other: Signature: Date: Description of work being performed: SECTION 1- SITE INFORMATION 74 NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes ❑ no 1.2 Assessors Plat & Lot Number - 1.1 Property Address: hj �J �� `�c�J�. �. (;�-.. I l''�°� Plat_ Lot_ Nearest Cross Street: 1.3 Historical District ❑ yes ❑ no Subdivision Name: Total Land Area Sq. Ft.: Has application been submitted to the Historic Commission? ❑ yes ❑ no Date: 1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System: ❑ Municipal❑ Private Well ❑ Municipal ❑ On Site Disposal System C:\bldg.forms\Bldgapp.res.wpd Page 4 Rev. January 19, 2001 C:\b1dg.fbrms\B1dgapp.res.wpd Page 1 Rev. January 19.2001 RESIDENTIAL 2001 SECTION 2 - PROPERTY 0WNER.`IHP AUTHORIZED AGENT 2.1 Owner of Record: 0{1�7-44 h /� mbq f7\1 I U i c / C��(� ' �— i(J U Jy �k� Name (print) Contact Address Phone Number 2.2 Authorized Agent: P ©� hr soQy� S� j Name (print) Contact Address Phone Number SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor License Number 3 8, Address Expiration Date Signature's Telephone-5c:2s 3.2 Registered Home Improvement Contractor: ",qi lb Applicable ❑ i 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 p'c, t�pME I �1YClt A4 PR C 'f Registration Number (if none, state "none") 5 ,6 c A:ldress ,s t 5 f'% f' r to VC, l Signature 'k ° /y" ' �' ele h one a G ' p 4" gJ / Expiration Date 3.3 For Residential Remodel Work Only i 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 1 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 you are applying under this section sign below: Signature: Your signature carries certain responsibilities, including but not necessarily limited to, general liability RESIDENTIAL 2001 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) SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL C 152µ§ 25) a 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: ❑ yes ❑ no SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable) ❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ ❑ woodstove (energy report required) (energy report required) fireplace ❑ 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 ❑ 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 (specify): ❑ Air conditioning - (separate unit) ❑ None of the above to be provided ❑ Hot Water: Gas Electric Fuel Oil Other Brief Description of Proposed Work: V SECTION - 6 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (S) to be completed by permit applicant 1. Buildin e Z 2. Electrical 3. Plumbin 4. Mechanical HVAC 5. Total = (1 + 2 + 3 + 4) *Estimated Total S SECTION 7A - OWNER AUTHORIZATION f` (to lie completed when owner's agent or contractor applies for building permit) (please rint) x SJ L}(C't , as Owner of the subject property hereby authorize /� PIlCh 0Ira) AMZ to act n my behalf, in all pa s relative to work authorized by this building permit application. Signature of Owner Date - ECTION 713 - OWNER/AUTHORIZED AGENT DE L RATI N" 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. i Alvl;Vl(kv Signature of Owner/Aut ori9d Agent Date nr C:\bldg.forms\Bldgapp.res.wpd Page 2 Rev. January 19, 2001 '' bldg. forms\Bldgapp.res.wpd Page :' Rev. January 19, 2001