The URL can be used to link to this page

BP-79892RESIDENTIAL ❑ phased Approval (R106.3.3) $25.00 APPLICATION FEE IS NON BE -FUNDABLE e& NON-TIBANSFERABLE t'oF k/ED DATE RECEIVED DARTMOUTH BUILDING DEPARTPEW� J. �.4 400 Slocum Road t €o x Dartmouth, MA 02747 2015 DEC -5 Phi 4: 04 1fi(4 ' 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 VBoard of Health: Signature: Conservation Commission: Signature: D.P.W.: Signature: Fire Chief: Signature: Other: Signature: Brief description of work being perfonned. I'1 NiS H E P ,2F r6'.j trigineenng ❑ Cross Connection Dater Date: Date: Date: Date: #rJ Exis-rant r rsMcgr 1.1 Property Address: �y Ch..�s,� o w 1.2 Assessors Map & Lot Number: Contact Person: MArYT 0 t'tSON Map �_ Lot _- r Phone Number: 5708' 138 5-22-y 1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System: ❑ Municipal ❑ Municipal CIYPrivate Well M**6n Site Disposal System 1.3 Historical District ❑ Yes R<0 Year Built ❑ Altering more than 25% per side of building Has application been submitted to the Historic Commission? ❑ Yes ❑ No Date: Revised 5 /13 ❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT RESIDENTIAL SECTION 2 -.PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner Record: tile- +-^es . aprTr N l I;LSON _ 2 `f Cm Kis i-mic Name (print) Contact Address Phone Number 2.2 Authorized Agent: 20(3E/L7 ,�TM&JN e 8 �PGE1,00D A✓r �Bg ig2-366Z Name (punt) Contact Address Phone Number SECTION 3 = CONSTRUGTION SERVICES 3.1 Licensed Construction Supervisor/Specialty License: License Number: CS -' O Sq 5-4 0 Company Name/Contractor Name: k06E27 ^NTrl4N Address: $ T-DLEW00D AVe- ri0. bA9-tnev7r1, Expiration Date: Signature: Telephone: 5-Or 11234C 2_ 124 q 1 2016 3.2 Homeowner Exemption - One & Two Family Only Section 110.R5.1.3.1 Exception: FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT 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: SECTION 4-.11f10R1#ER`S GOMQEIVSATION INSURAt�ICEOPIDAViT:(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: Eames ❑ No SECTION 5 DESGRIP`I'ION .OF PROPOSEE3INORK {Ghec[c all ajiplicablej;= ❑ Deck ❑ Pool ❑ Repairs "Iteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove ❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding ❑ Replacement window/door (Energy report required) (Shed/Garage) (Energy report required) No. of windows Doors ❑ DEMOLITION (specify): Location of debris removal (per MGL C.40 Sec 54): ❑ Dumpster on site ❑ Dumpster On Street Facility Name: Location: *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 13 Hot Water: Gas Electric Fuel Oil Other SECTION 6 ESTIMATED.G©NSTRUGTION COST Item Estimated Cost ($) to be completed by permit applicant 1. Building 27-20.00 2. Electrical `Z$�OD . 00 3. Plumbing 4. Mechanical (HVAC) 5. Total +2+3+4) 24 '720.00 SECTION 7A --OWNER AUTOFT HORIZATION {fo'be caaripleted ijvhen OwnWS agenf or con#ractor applies for building permit) (Please Print) Ae/ I • A`tiH�-w k), C` ohJ , as Owner of the subject property hereby authorize CG•v s7,w&r1oil .1_ ✓G , to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date p SECTION 7B = OWNER/AUTHORIZED AGENT DECLARATION 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. Slgnatur-�e of Owner/Authorized Agent Date SECTION 8-`OFFICE/(NSP)tCTOR;S'NOTES n Total Permit Fee: $ Less Application Fee: $25.00 Remaining Balance: $ Iy �'j "� Other $ Amount $ Gross Area - New Construction total sq. ft. Gross Area - Alteration total sq. ft. _ /V Permit Issued to: t 5 . f lkJ DESGF2IPTION UFIIVORk.BEING FERFpRMEDh , . t S��ts's 8r 8 7 6 5 4 3 A) C B A 319.50 8 WATER PUMP TANK 68.00 47.50 STAIRS UP o TO BqLK- HEAD DOOR POLY "-qcLr-';r- V'00 "a I ep, ilk, FbAll pis tqA-rtod V- [I.Jj rA LLCD 2 �GOvf 4JT to T)j'e0l1&i40V WINDOWS 324.63- 156.00 0�5 arc -9 ptti ELECTRICAL---,. I PANELS 1 60.00 .1 WAL'L rgAtlii�J&- 16- otj cc-N-fsjc-'-'r jpp_r-jjUoe6' -ne6^-TcD 5 1 LA's CAp pF-r ^,-Jp #OAV (,LVfl> ONTO r-)c tj co,ve, xcre- COLUMNS HOLE FOR SUMP PUMP 024.50— 36.00 OIL TANK BOX IR HOT WATER TANK C 11% L My ur f c B UNLESS OTHERWISE SPECIFIED: NAME DATE DIMENSIONS ARE IN INCHES DRAWN M.N. 11/20/14 TOLERANCES: TITLE: FRACTIONAL± CHECKED- A 'ANGULAR: MACH± BEND± ENG APPR. BASEMENT LAYOUT TWO PLACE DECIMAL ± fJ )l Otj)� A T THREE PLACE DECIMAL ± MFG APPR. 24 Chriisfine Drive wo V E�'j Ur INTERPRET GEOMETRIC �TOLERANCING PER: Q.A. Dartmouth, MA PROPRIETARY AND CONFIDENTIAL COMMENTS: THE INFORMATION CONTAINED IN THIS MATERIAL N/A SIZE DWG. NO. REV DRAWING IS THE SOLE PROPERTY OF MATTHEW NIELSON. A N . . .......... . . ...... . . . - ----- BASE_ 2 A 5-Or 112-3692- REPRODUCTION IN PARTORAS A WHOLE : FINISH NIA WITHOUT THE WRITTEN PERMISSION OF NEXT ASSY USED ON .. .... . ... ... MATTHEW NIELSON IS PROHIBITED. APPLICATION DO NOT SCALE DRAWING SCALE: 1: 128! WEIGHT: N/A -,-SHEE,T-1,OFI,-l--.-, 7 6 J- ------ 5 -- 4 3 2