BP-32399RESIDENTIAL -2002
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON -TRANSFERABLE «
A O
SECTION 8 INSPECTOR'SREVIEW/COMMENTS
-
1. 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 work -sheet): Date:
6. HOLD reason: Date:
7. HOLD subject to Zion)*ng�Board of Apppe is action: Date:
8. Comments: lt7 y (`, �+, ,ifs_ /d-, r.3, L/
9. Inspector's
S>rLTION V f APPLIC"T NOTIFICATION
Date:
Applicant inform of above T' e: Clerk:
Comments: el�
SECTION 10- OFFICEVNSPECTOR'S NOTES -
Total Permit Fee: $ Less Application Fee: $ 25.00 Remaining Balance: $ 626,
TOTAL FEE: : 00 Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued To:
SECTION
1
i�tAL COMMENTS/SKETCHES
13`
61
N
a
C:\bldg.forms\Bldgapp.res.wpd Page 4 Rev. January 1, 2003
RESIDENTIAL
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE dt NON -TRANSFERABLE- j
DARTMOUTH BUILDING DEPARTMENT
z BATE RECEDED-
. � sg.. i
I ,400 Slocum Road, P.O. Box 79399
Z $ (4
Dartmouth, MA 02747 711
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO F:i, :IIILY DWELL��
THIS SECTION FOR OFFICIAL USE ONLY
-
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RECEIVED BY:.
t•`.,3's "' a' �; 1y,,, "` y *'�}' �5.Sy..,�"�'C "t4tih� yVsY�, `� '7".«.' ..t.•�.. y�e:. r-3.'a�.it:.9�r`3'Y3,,.a'�':'��c:
3c
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. _ = BUILD G MITNUMBER
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to
DATE SENT FOR REVIEW: ' {- > DAT1r. -,
OK TO ISSUE SIGNATURE' ATIV _
?• s.. «B 'ding on=ZjtdFofBflAp
c s
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Zoning District.= posed Use._% 'Y Zone C a B a.� Q �Outsidi: ET
4tZiin 7.�`�gnifer�Lone
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.�r..
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED« . 4 "<
s,'
❑ Board of card of N a Con. Com l�Demo� 'O DPW :I F.Iec ll Report
Appeals ;Health rtj �� }"� Affidanf kz Card S'entrCkT ' F#illow ups r
� .� >� �"; �� "soar ���� � � �',� ,,�,t.- ��,."`s-�,V �'.�•„x� ,r%A�'i�4..�*ea�5:� .,... ,
❑ Fire ❑ Gas CI Planning Board" 13 Sewer Card' �� fib. Water Card �� k�oning� � Othe "� _
Chief cutoff, Y�II r s -' !Cut Off ,` /Cut Off rtevieiR*�� <
s _R,a. p t+, : '' „•j t x j 'a✓ 7a ^�,a ..r , k'� ' r,'°�" ik''` r �"'�`Y'� ,,g'o L a '_
^� r , „ ... _S..i w.�++ -. y.._.-...... •� 3 T � �s-Y. u�'{=iw�ilN^T fY•+t :..
REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF=APEEMT�"
DEPARTMF Ar,APPRnVpT.
Zoning Review: Signature: 0& Date: L
Energy Report: Signature: Date:
ire Chief: Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other: Signature: Date:
Description of work being performed:
SECTION 1 SITE INFORMATION '`'* .; " ; "{ 4
NUMBER OF PLANS SUBMITTED: SITE PLAN SUBM=D: ❑ yes ❑ no
1.1 Property Address:,,%4iy dAcOr"/�/)uii't'(Pv &d 1.2 Assessors Plat & Lot Number:
Plat -2_-S Lot _6_5� -
Nearest Cross Street: ����� � /l �� �''��.
Subdivision Name: 1.3 Historical District ❑ yes ❑ no
Total Land Area Sq. Ft.: Has application been submitted to the Historic Commission?
❑ yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System:
�unici al ❑ Private Well ❑ Municipal ❑ Af tte Disposal System
C:\bldg.forms\Bldga e_ d Pa 1 Rev. January 1, 2003
"G-
2.1 Owner of Record:
.r`—� •(�'." "'"iG `'i � `.af (,�'l! �
V' / ( �YJ%�/l O /—� L7 ��"" [`� / `C-A� �v� � /�
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Contact Address Phone Number
Name (print)
c$ECTION 3 F40NSTRUGTION SERVICES
+'�?l "'s..'� +'.t;r
?T. '>• ...a�•-f _.arx x'k y,;w.c.__ t.,Z y�. .rr:...-..: _ _ -
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
i,y signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
Oate
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 BE RS 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 arc applying under this section sign below:
Signature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
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)
t : SECTION 4 - WORKER'S COMPENSATION INSURANCE AFFIDAVM
F
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 — (check p DESCRIPTION OF PROPOSED WORK (chk A ap licable) � ,
• - . ...: ,., ..... .. ...�� _: �_ _ .
❑ 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 I 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: ��6 �✓ ,�
: X / t, 1
5 SECTION 6 ESTIMATED CONSTRUCTION COSTS' `"' r#
Item
Estimated Cost ($) to be completed by permit applicant
1 Rnildina
� F1Prtrir:ul
Phrmhina
A MPrhnnirnl (NVAC)
5. Total = (I + 2 + 3 + 4)
* Estimated Total $
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402M,
` ': SECTION 7A - OWNER AUTHORIZATION�'�,li}4
(to be completed when owner's agent or contractor apphes, for bi ldmg.,pc mdt) z
(please print)
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.
Signature of Owner Date
SECTION 7B - OWNER/AUTHORIZED AGENT DECLARATIONS
as Owner/Authorized Agent hereby declare that the statements and information
on the foredoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Signature of Owner/Authorized Agent �r 4 Date ,
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