BP-23859RESIDENTIAL
-LE
2001
SECTION 8 - INSPECTOR'S REVIEW/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):
5. DENIED (see project review worksheet):
6. HOLD reason:
Date:
Date:
Date:
7. HOLD subject to Zoning Board of Appeals action:
8. Comments:
Date:
9. Inspector's Signature:--
SECTION —'APP I AN NOTIFICATION
Date:
Applicant info ed f above Date: Cler
Comments:-=.—
SECTION 10- OFFICEVNSPECTOR'S NOTES
Total Permit Fee: $
Less Application Fee: $ 25.00
Remaining Balance: $
TOTAL FEE: (D D Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued 0* 3 Y
4 1T
ale
SECTION 11 -ADDITIONAL COMMENTS/SKETCHES
Aff`
a
I
RESIDENTIAL 2001
0 FO UNDA TION ONLY
$25.00 APPLICATION FEE IS NON -Dr -FUNDABLE & NON -TRANSFERABLE
LIT" DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT-
lp.i7
�LL400 Slocum Road, P.O. Box 79399
Dartmouth, MA 02747
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
..
,�-,,TIHS SECTION FOR OFFICIAL USE -ONLY
RECEIVED BY:
BUILDING PE ' RMIT.
DATE SENT FOR REVIEW: NUMBER.
-DATE ISSUED:.'
DATE
OK TO ISSUE - SIGNATURE:
ner/Inspe OfLuildgs
Building Co Zoning Distract: roposed Use. _, ;.Zone:` [� .❑ B ❑`A ❑ V Outside Flood"Zone'❑ Aqulfer Zone�_`,
or
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED*
`b_bem`,'o _-_0 DPWt' "Z'13 Ele
E3Board of.':'- -0 Board of.:`_' 13Con.Com. C. -L [3 Eneii67teport
Cut of
Sent Appeals Affidavit 7;k i---:C- ard-up Follow
Zoning as 13 P anning Board* E3 Wate Card{ 13 Fire 0 6 Sewer Card r Ca 0 Other
Chief Cut off
Review* Cut Off Cut Off
REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSU
ANCE OF A PERMIT.
DEPARTMENTAL APPROVAL
Zoning Review:
Energy Report,
Fire Chief -
Board of Health:
Conservation Commission:
Other:
Signature:
Date:
Signature: - - -Date:
Signature:
S
Signature: Date:
Description of work being performed:
SECTION I - SITE INFORMATION
NUMBER OF PLANS SUBMITTED: SITE PLAN SUBMITTED: Gl<es 13 no
1.1 Property Address: /:�Oe5 farm 1017 1.2 Assessors Plat & Lot Number:
Plat-4-27— Lot
Nearest Cross Street:
Subdivision Name:
Total Land Area Sq. Ft.:
1.4 Water Supply (MGL c 40 § 54):
0 MunicipalD451rivate Well
1.3 Historical District 0 yes B-n-o
Has application been submitted to the Historic Commission?
0 yes 0 no Date:
1.5 Sewage Disposal System:
0 Municipal all,'n Site Disposal System
11
F
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RESIDENTIAL 2001
SECTION 2 PR PERti' WNF SHiP A H RIZED AGENT
2.1 Owner ofRecord:
s6�
/?Ober � � Mar1 rO�'t'D�1 � �: �/4�'P� �l'rn'� �9/I e �
Name (print) Contact Address Phone Number
2.2 Authorized Agent:
L1r oale ' Ao� ` Y 1:?s S& - `%%1 //p
Name (print) Contact Address Phone Number
t�JI E% IIVt\or'nVII.GJ
- - - -
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor /?O fiMdjP0( 5 �% / /e I% Q
License Number 07?17 3 (�,
Address o2a CT 14005117ef lllele-Expiration
Date
i/71-2co5�
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 a ec?r el, // t
CiC2ls �'S
R„
Registration Number (if none, state "none")
Address y�(lS�
SignatureIg!gW go ) Telephonel%�' 9�c1 !/�1J
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:
Horne 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. .r ;
Exception: Any .Homeowner�performing work for whick*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:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
RESIDENTIAL
2001
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 (MGL C 152 § 25)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failyre to provide this affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: Byes ❑ no
SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable)
❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ ❑ woodstove
(energy report required) (energy report required) fireplace
❑ deck opf 'oo1 ❑ 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 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:
lns a a o� a i `oun Sub/MMin 1 0 00
i 7 ii
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost ($) to be completed by permit applicant
1. Buildin
2. Electrical
3. Plumbiniz
4. Mechanical HVAC
5. Total = (1 + 2 + 3 + 4)
cpd
* Estimated Total $ %3 .00 0 -
SECTION 7A - OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(please print) /— 1
I, malzl a GO le -do , as Owner of the subject property hereby authorize C/"
t a n my behalf, ' all ma ers rel tive to work authorized by this building permit appiic Lion.
JLC.f'1�
y1j(
Signature of Owner Date
SECTION B- OWNERAUTHORIZED AGENT DECLARATION
I� , 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.
Signature of Owner/Authorized Agent Date
C:\bldg.forms\Bldgapp.res.wpd Page 2 Rev. January 19, 2001 C:\bldg.forms\Bldgapp.res.wpd
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Pn 10 onni
f
ESTATE LOT
2A
ESTATE LOT
28
qo AREA=240,567 SF
q �7
EASMING
FOUNDATION
A 80 -2(-)'
12
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