BP-21719RUESIDENTIAL
SECTION 8 - INSPECTOR'S REVIEW/COMMENTS
_ 1301
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 Si
u 9ECTION 9 - APPLICA T NOTIFICATION
Applicant informed of above Date: Time:
Comments:
Clerk:
SECTION 10- OFFICE\INSPECTOR'S NOTES
Total Permit Fee: $j • (� Less Application Fee: $ 25.00 Remaining Balance: $
TOTAL FEE: �- Cross Area - New Construction total sq. ft.
SECTION 11- ADDITIONAL COMMENTS/SKETCHES
RESIDENTIAL 2001
�FOUAD,,9 T.T.ON ONLY
$25.00 APPLICATION FE IS NOX' i%EFYINDABLE & NON -TRANSFERABLE
DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O. Box 79399
Dartmouth, MA 02747 s ;
508-910-1820 FAX 508-910-1838
NUMBER OF PLANS SUBMITTED:
1.1 Property Address:117
Nearest Cross Street:S
Subdivision Name:
Total Land Area Sq. Ft.: is 3
1.4 Water Supply (MGL c 40 § 54):
SITE PLAN SUBMITTED: Xyes ❑ no
1.2 Assessors Plat & Lot Number:
Plat_ Lot_ �_
1.3 Historical District ❑ yes ); no
Has application been submitted to the Historic Commission?
❑ yes )<no Date:
1.5 Sewage Disposal System:
alit a�p.�cs.wpd Page 4
Rev. January 19, 2001
C:\b1dg.f6rms\B1dgapp.res.wpd
❑ MunicipaIV Private Well
Page I
❑ Municipal &On Site Disposal System
Rev. January 19 inn i _
RESIDENTIAL
2001
E TI N 2 R PERTY b`riti 4F;P/AUTH RiZED AGENT
2.1 Owner of Record:
ZSPG '�a�l�atsct,s �►M� o?.�ly
Name (print) 1 so81 992 �Sa�
Contact Address Phone Number
2.2 Authorized Agent:
UoNaL�zu�c
_ ��� c't9 �-i Fa't^I"t0
Name (print) C
—T� Contact Address
Phone Number
SECTION 3 - ONSTR ON SERVTCES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor RO
Address A -o, %.I— _ .. .-
Signature Telephon
3.2 Registered Home Improvement Co actor. "
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
Address
Not Applicable ❑
License Number(�,2D
Expiration Date
ozl 'e4 e,(no 3
Not Applicable
Registration Number (if none, state "none")
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, AM 02108, (617) 727-8598
Owners Name (print)
Signature
Date by signing the above, the home owner acknowledges that there will be no eligibilty to the Guaranty Fund
3.4 Homeowner Exemption - One & Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR O1VN 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 dwelline, 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. Failure to provide this affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: Xyes ❑ no
SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable)
new constrDuc`h�on Ot'�Lq ❑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_ :!7� no. of bathsZ
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) el oil electricity, other (specify):
HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):_
13 Air conditioning - (separate unit)
13 None of the above to be provided
A Hot Water: Gas Electric Fuel Oi "'- ti��Other
Brief Description of Proposed Work:
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item I Estimated Cost ($) to be completed by permit applicant I
5. Total = (1 + 2 + 3 + 4) -Estimated Total $
SECTION 7A - OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(please print) skcpxT \.,ors
SAhm% A
as Owner of the subject property hereby authorize of
to act on Iy beh �er
a rs relative to work authorized by this building permit application.
Signature of O Date
SECTION B- OWNERAUTHORIZED AGENT DECLARATION
I, R`- `R��t° , as Owne uthorized Agen ereby declare that the statements and information
on the foregoing application a e true and accurate, to the best of my know edge and belief.
Signed
penalties,,,of perjury.
Signature of Owner/Authorized Agent
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Rev. January 19, 2001
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Date
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OCTOBER 11, 2001
38'
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LOT 23
LOT 28
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PLOT 27
LOT 21-7
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4/o V 0 1 2001
SCALE 1 " = 100'
I certify that the foundation
shown on this plan is in
compliances with the applicab
Zoning By -Laws in the
Town of DAR TMO UTH.
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SUeoMSION LOT 20
YAP
LOT
66.313 Sq. Ft.
FllinEl COPS'
LOT
ENCHMARK 44'
HEADWALL
ELEV 100.00
EXISTING WELL
98'
PROPOSED TOF
ELEV 100.00 95'
EXISTIN TOF 445'
ELEV 100.12
PLOT 27
LOT 21-7
2.23 AC t
SCALE 1 " = 60'
Correia's Engineering Inc.
LAND SURVEYING
8 Grinnett Street CIVIL ENCINEERM
South Dartmouth, MA. SUBDIVISIONS
02748-2314 SITE PLANS
Telephone (508) 999-6052 AS —BUILT PLANS
Fax (508) 979-5949
Joseph E. Correia III Pres. & Joseph E. Correia IV VP.
AS -BUILT
0 UNDA TION PLAN
ABNOR PO T TER WA Y
LOT 21. --7
in
DAR TMO UTH, MA.
prepared for
BOB LONG
OCT 23, 2001
FILE # 01-0092 JEC III
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