BP-41627RESIDENTIAL 2005
;SECTION 8'- INSPECTOR'S REVIEW/COh'[NIENTS
1. Date plan reviewed:
2- 30 days to review period expires:
3. OK to issue date:
4. OK to issue subject to requested subn- ttals(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:
9 - APPLICAlYT NOTIFICATIO
Applicant inf ed of a e Date: y J Time:
Comments:
1 !'
S
RESIDENTIAL
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE
D TE RECEIVED
o-•� TFt %Y '.
DARTMOUTH BUILDING DEPARTMENT
3 400 Slocum Road, P.O. Box 79399
Dartmouth, MA 02747
508-910-1820 FAX 508-910-1838
APPLICATION T9TONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY
RECEIVED BY: 77TBUrLDINGPERMIT.NUMB R:
DATE SENT FOR REVIEW: DATE'ISSUED
OK TO ISSUE =SIGNATURE:
,,,,,.➢ATE_
Building Commissioner/Inspector of Buildings
Zoning Districti5l9.6 Proposed Use:'4 Zone: C D B C]A D V ....:Outside Flood Zone ', ❑ Aquifer
THE FOLLOWING AGENCIES SHOULD'BE NOTIFIED
D Board of D Board of DCon Com ❑Demo D DPW '; D Elec D Energy Report
Appeals Health -- Affidavit Card Sent'=Cut Off �Fo[ow-up*
K m-
D Fire ❑Gas D Planning Board* D SeFver Card Q Water CardD Zoning D Other
Chief " "Cut Off, -: /Cut Off 1 Cut Off Reviews
*'REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCESOF°A PERMIT. -
D PARTMENTALAPP OVAL _'
A�
`
Zoning Review: Signature: �J Date: 5-
Energy Report: Signature: Date:
Fi Chief: Signature: I Date:
Board of Health: Signature: h2, Date:
Conservation Commission: Signature: Date:
Other: Signature: Date: _
Description of work being performed,&�
SECTION I - SITE INFORMATION
NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: ❑ yes ❑ no
1.2 Assessors t t Num
71property Address: 148 ROCK O' DUNDEE ROAD -
Pla
Nearest Cross Street:
Subdivision Name: 1.3 Historical District ❑ yes ❑ no
Total Land Area Sq. Ft.: Has application been submitted to the Historic Commission?
❑ yes ❑ no Date:
1 Water Supply (MGL c 40 § 54): 1.5 ge Disposal System:
❑ Municipal(N Private Well ❑ Municipal ? 0n.Site Disposal System
2005
R
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RESIDENTIAL
.1 Owner of Record:
BARRY R. & JANICE M. HODGE
Name (print)
2.2 Authorized Agent:
Name (print)
Contact Address
Contact Address
Phone Number
Phone Number
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor I License Number
Address
Signature Telephone
3.2 Registered Home Improvement Contractor:
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
Address
Signature Telephone
3.3 For Residential Remodel Work Only
Expiration Date
Not Applicable ❑
Registration Number (if none, state "none")
Expiration Date
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
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
YourYA*dture c&ies certain responsibilities, including but not necessarily limited to, general liability
RESIDENTIAL
2005
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 (14IGL''G°152..§ 25) s=
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 PROPOSEDJVORK (check all applicable)
❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/
(energy report required) (energy report required) fireplace
❑ deck ❑ pool ❑ accessory bldg
(shed/garage)
* If new construction, please complete the following:
Single Family: no. of bedrooms
❑ replacement window/door ❑ other ❑ demolition
no. of windows_ doors_ (specify below): (specify below):
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:
K EXISTING BULK COAL STOVE TO BE-RERLACED.WITH COAL STOKER -MODEL I
Item
5.Total =(1+2+3+4)
(please print)
Estimated Cost ($) to be completed by permit applicant
* Estimated Total $ 2
I, , 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.
5 OCTOBER 2005
Signature of Owner Date
l BARRY R . HODGE , as Owner/Authorized Agent hereby declare that the statements and information
foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains pnd ,penalties of perjury.
of Ownel/Authtized Agent
Date
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