BP-612741. Date plan reviewed: OCT 0 r4 2010
2. DENIED (see project review worksheet):
Date:
3. HOLD
Reason: Date:
4. HOLD subject to Zoning Board of Appeals action: Date:
Comments:
Inspector's Signature:
Applicant informed
Comments:
Time: ,
Date: OCT 0 -4 2010
Less Application Fee: $25.00 Remaining Balance: $ �---
Total Permit Fee: $ � �
Other $ Amount $
TOTAL FEE: Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
I Permit Issued to:
'i N SECTION.11-ADDITIONALCOMMENTSISKETCHES
Page 4
RESIDENTIAL ❑ Approval in Part (Per 780 CMR.5111.13)
SL.11MU AYYL11UNI'll WN VILE 1J NSPIN UIL-FU1\IWLHEI ati 1i�7111=1'iSE[il� l LHA1tLL
rl p4 ;.,.DATE RECEIVED
ryTH T DARTMOUTH BUILDING DEPARTMENT
i
f 400 Slocum Road P.O. Box 79399
-EP 28 10
Dartmouth, MA 02747
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
Zoning Review: Signature: ..,g �� � Date: OCT 0 ; 4 2010
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
Board of Health: Signature: f . Date:
Conservation Commission: Signature: Date:
Other: Signature: Date:
Brief description of work being performed. ( v\ !, �Gc� hc�t•
1.1 Property Address: .193 Cl1 e-r 1113 J"e-r �h • 1.2 Assessors Map & Lot Number:
Lot Area (sf.) Frontage Map Lot -
Required Provided
Front Yard 1.3 Historical District ❑ Yes ❑ No
Side Yard '
Year Built
Rear Yard
❑ Altering more than 25% per side of building
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disp al System: Has application been submitted to the Historic Commission?
❑ Municipal ❑ Private Well ❑ Municipal n Site Disposal S stem ❑ Yes ❑ No Date:
13-CONSTRUCTION PLANS ffSITE PLAN ® ENERGY REPORT
Page 1
IiESIDENTML y
C
O
P
Y
O
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E
N
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E
(S)
Address:
Signature:
Telephone:
3.2 Registered Home Improvement Contractor:
Are you a Home Improvement Contractor subject to (780 CMR.110.R6)? ❑ Yes []No
Are you claming exemption from the requirements?
❑ Yes ❑ No
If Yes, Go to Section 3.3
Company Name/Contractor Name:
Address:
Signature:
Telephone:
Expiration Date:
Not Applicable ❑
Registration Number (if none, state "none"):
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
am a Homeowner performing all the work myself.
Owners Name (print
Signature: *;By
gning the above, the homeowner acknowledges that there will be no eligibility 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
5108.3.5 Licensing of Construction Supervisors: Except for those structures governed by Construction Control in Section 116.0, effective July 1, 1982, no individua
shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration, repair, removal or demolition involving the structural elements of building
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 Constructioi
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 Homeowne
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 whic
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 tha
one home in a two-year period shall not be considered a Homeowner
If you are applyin der thi on sign below:
Signature:
ca
but not necessarily limited to, general liability
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: ❑ Yes ❑ No
SECTION 5 =. bESCRIPTION OF PR )POSED WORK (Check all,applicatile�
❑ Deck Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Roofing/Siding ❑ Other
(Energy report required) (Shed/Garage)
(Specify below)
❑ Addition ❑ Replacement window/door ❑Demolition
(Energy report required) No. of windows Doors
(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
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Description of proposed work:
Date
Page 2
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Page 3
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