BP-56999Inspector's Signatu
Applicant informed of above:
Comments:
Date: 6 `�� �j—e>- 1
Date: Time: r� C� _ Clerk:
i
` _SECTION.10 -_OFFICE/INSPECTOR'SNOTES
"`
Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: $
Other $ Amount $
TOTAL FEE:
Permit Issued to:
7 Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sa. ft.
1
7�a ciri2
RESIDENTIAL ❑ Approval in Part (Per 780 CMR.5111.13)
$25.00 APPLICATION FEE IS NON BE -FUNDABLE A NON- BANSFEBABLE
DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT
o
400 Slocum Road, P.O. Box 793994
Z G Dartmouth, MA 02747
Phone: 508-910-1820 Fax: 508-910-1838
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIALUSE ONLY
Zoning Review: Signature:
Energy Report: Signature:
Date:
Fire Chief. Signature:
Date:
Board of Health: Signature:
Date:
Conservation Commission: Signature:
Date:
Other: Signature:
Date:
Brieidescription of work being performed. ,
1 Property Address T 7`f AQC/G U %JQHGtee ^C9
Lot Area (sf.) Frontage
Required Provided
Front Yard
Side Yard
Rear Yard
1.4 7'Nater Supply (MGL 7rivate
4):
+�/ ❑ Municipal Well
1.2 Assessor p ,Lot Number: ;�
Map Lot 7.
1.3 Historical District ❑ Yes ❑ No
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
1.5 Sewage Disposal System:
❑ Municipal tP-(7n Site Disposal System
13 CONSTRUCTION PLANS ® SITE PLAN
PESIDENTI L
SECTION 2: PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner Record:
Name (print) Contact Address Phone Number
2.2 rized gent:`,61r�
Name (print) (�' • h Contact Address Phone Number
I�
SECTION 3 = CONSTRUCTION'SERVICES
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor: I License Number:
Address: Expiration Date:
WSignature: Telephone:
V3.2 Registered Home Improvement Contractor: Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR.110.R6)? ❑ Yes ❑ Nc
If No, go to the next section!
Are you claming exemption from the requirements? ❑ Yes ❑ No
J 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
❑ 1 am a Homeowner performing all the work myself.
Owners Name (print): iflari a I 17-L (n 1 -i jrnU
Signature---
By
�— By signing the above, the homeo�—wner acknowledges that there will be no eligibility to the Guaranty Fund
Date: TZrU 9
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
5108.3.5 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 S I t be considered a Homeowner.
If you are applyin er s on sign be
Signature:
—Y16dr signature carries certain res-oclisibilities, including but not necessarily limited to, general liability
SECTION 4 WORKER'S COMPENSATION INSURANCEAFFIDAVIT (MGL c 152 § 25)
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
ECTION 5 -'DESCRIPTION OF PROPOSED WORK (Check all applicable) "
❑ Deck vool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction' ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage) (Specify below)
❑ 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: ��.1� ; ,Q I S, V4 >-® t4 -906
V, r11ke Dne, 2 t -
SECTION 6 -'ESTIMATED CONSTRUCTION COST
Item Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC) e1j14-�
5. Total =0 +2+3+4)
SECTION 7A -OWNER AUTHORIZATION
(to be when owner's agent"or coritractorapplies forbuilding permit) s
(Please Print)
1, , as Owner of the subject property hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
;SECTION 7B-'OWNERIAUTHORIZED AGENT DECLARATION "
as Owner/Authorized Agent hereby declare that the statements and information
Le foregoing application are true and accurate, to the best of my knowledge and belief.
ed under the pains and penalties of perjury.
Sign ure of Owner/Authorized Agent Date