BP-12278. Residential
1999
Residential FOUNDATION ONLY 1999
$25.00 APPL C TION FEE .IS NON-REFUNDABLE
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 worksheet): Date:
6. HOLD reason: Date:
7. HOLD subject to Zoning Board of Appeals action: Date:
8. Comments:
9. Inspector's Signature:
IApplicant informedrof �g�
Comments: v// / I
v,
Time � Clerk:
Total Permit Fee: 47--0 Less Application Fee: $ 25.00
TOTAL FEE: Gross Area - New Construction total sq. ft.
Gross Area - Alteration total so. ft.
Permit Issued
Remaining Balance: $
DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT
fo 400 Slocum Road, P.O. Box 79399
Dartmouth, MA 02747 Inn ' `'.',tl� 19
508-999-0720 FAX 508-999-0738
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Zoning Review: Signature: (10�__-� 1 Date:
Energy R:fort: Signature: Date:
Fire Chief: Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other: Signature: Date:
Description of work being performed:
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED:
■ 1�
r 1.2 Assessors Plat & Lot Number:
1.1 Property Address: .S'ClAd e S C/N &,,7-A% <
Plat Lot
Nearest Cross Street: Se Oj/70- S Ccy/W-0A R0*_4
Subdivision Name:- 1.3 Historical District Dyes t'io
Total Land Area Sq. Ft.:
Has application been submitted to the Historic Commission?
❑ yes �4 Date:
1.4 Water Supply (MGL c 40 § 54): 1 1.5 Sewage Disposal System:
❑ Municipal private Well 1 ❑ Municipal Wh Site Disposal System
c:\wpwin\forms\bldgapp.res Pan 4 Rev. July 7, 1999
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Rev. July 7. 1999
Residential
1999
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2.1 Owner of Record:
CiFP,cS% F(9�lYs_
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
ontact ddress Phone Number
.... ;:. ,...:....::
ERV FS
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor
License Number
Address
Expiration Date
Signature Tele n
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to 8 CMR-6)? ❑ yes ❑ no
o, go to the next section!
Are you claiming exemption from the requireme ? ❑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 ly
PERSONS CONTRACTING W UN ISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONS OR COMPLAINTS 1 o w ite:
Home Improvement Co ctors Registration, One Ashburton Place - Room 1301, Boston, ,LIA 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 applyi7��elow
y��\
Signature:
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
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