BP-14695RESIDENTIAL
2000
RESIDENTIAL 0 FOUNDATION ONLY 2000
$25.00 APPLICATION FEE IS NO! -r.ZF TNDABLE & NON TRANSFERA13LE
L Date plan reviewed: —
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:
19. Inspector's Signature:
Applicant inform
Comments: t I
Clerk:
Total Permit Fee: $ 9-S ` CO Less Application Fee: $ 25.00 Remaining Balance: $
TOTAL FEE:s. 00 Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
I
Permit Issued To- 3a- __- Q'.—.,6
h
,` - ` • 'DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT`
`o 400 Slocum Road, P.O. Box 79399 2 ' It.°." 13 Ail 11:
3o yf Dartmouth, MA 02747
`.•:_'h�==' 508-999-0720 FAX 508-999-0738
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Zoning Review: ® Signature: ` Date: 3 _1 se—
Energy Report: Signature: Date:
Fire Chief Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: Date: �z
Other: Signature: Date:
Description of work being performed:
NUMBER OF PLANS SUBMITTED:
AVn
lrroperty Address: 1, a p' �ncQ�p Q
Nearest Cross Street:
Subdivision Name:
Total Land Area Sq. Ft.:
1.4 Water Supply (MGL c 40 § 54):
❑ Municipal 0 Private Well
SITE PLAN SUBMITTED: I a es ❑ no
1.2 Assessors Plat & Lot Number:
Plat
1.3 Historical District ❑ yes ❑ no
Has application been submitted to the Historic Commission?
❑ yes ❑ no Date:
1.5 Sewage Disposal System:
0 Municipal ❑ On Site Disposal System
c:\wpwin\forms\bldgapp.res Page 4 Rev. January 20.2000
RESIDENTIAL
2000
Ecrtt..;ritarEx€.c�r^v> t�st�€xP.I:Attttt'R1zIl�A�l yr
2.1 Owner of Record: P
VAe s.RgLO
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
..:
ECTI Li]'..» C7n5TRLI! 1Ft� SER:1. . .
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 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 (print)
Signature
by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
Date
..4 Homeowner Exemption -One &Two Family Only
2 Y Y
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.
f you are applying under this sectn below:
Signature C ;ig�
Kr signature carries rtai responsibilities, including but not necessarily limited to, general liability
RESIDENTIAL 2000
NOTICE TO LICENSED CONTPUCTORS: 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)
S. W,TIO4 i�blit ER'$ U4tPE`«St1 I01! I S RA\C riFF[I3A {J€T EltscL c 52 2
.....
_:....
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
I CTC#�15►r5 ESCRIMM )1 t F PROPOSE i�4RT€ (eht Ck alI appllca le}
❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ ❑ woodstove
(energ% report required) (energy report required) fireplace
❑ deck Cpoo] ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ demolition
(shed./garage) no. of windows doors (speciA- below): (speciA, below):
* If new construction, please complete the following:
Single Fancily: no. of bedrooms no. of baths
Two Family: no. of bedrooms unit 1 no. of baths unit I
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:
30' At000e Ir`
O
SETI£� S = > ESrI CIA ! EI3 COriS" TRi tC TIEiI COSTS
Item Estimated Cost ($) to be completed by permit applicant
1. Buildin
2. Electrical
3. Plumbinia
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4) * Estimated Total $ 00
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>;:;: ;;;::,:>::; :>::>:::.;::::;.::c;:::::::':. t:btscodc fete a ,:::>:>::><>::::;;;:::::.>;:::
...:..:::.... ......:..::.::::::.:::::::::( ..::::. p : -.:_ �vlse Qwrc r s ag pt or antlractor applies hrr 1[rnlitiin .unit :...:...:...::.::::.:::.:...
.......................................................................... g.p...........)............................ .....................
(plea a print) (�
I, �� �� S i� Pf `i ' , as Owner of the subject property hereby authorize rc� n iC�t�l S
to act on my be , ' al] afters relative to work authorized by this building permit application.
A 1Z
Signature of ner Date
$C i Ci i 7 1ir ,
.:
#sF $ 4 1�11�llAt iH(iil IZ>D r1>�i�i7"::ffl CY AI2ATlON: >::
(2_ _,acaner/ uthorized Agent hereby declare that the statements and information
on the foregoing application are true and accurate, tote est of my knowledge and belief.
Signed under the pains and penalties of perjury.
� U
Ignature of wner/Autho ed A nt Oate