BP-32775RESIDENTIAL 2004
❑ FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE do NON -TRANSFERABLE
nUrH 9sP, DARTMOUTH BUILDING DEPARTMENT°' DAT>rRiIVED
/0 y
400 Slocum Road, P.O. Box 79399�# 9: 11
Dartmouth, MA 02747
508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Zoning Review: Signature: Date:
Energy Report: Signature: Date:
Fire Chief: Signature: Date:
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
Other: Signature: Date:
Description of work being performed: 45,e L5
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED: ❑ yes ❑ no
/ 1.2 Assessors Plat & Lot Number:
1.1 Property Address: 3� G
Nearest Cross Street:.jG�
1.3 Historical District ❑ yes Elno
S 14ir_V416-Mi-I 4A42"jg
Has application been submitted to the Historic Commission?
Total Land Area Sq. Ft.:
❑ yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54):
❑ Municipal Wrivate Well
1.5 Sewage Disposal System:
❑ Municipal ❑ On Site Disposal System
C:\bldg.forms\Bldgapp.res.wpd Page 4 Rev. January 1, 2003
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Page 1
Rev. January 1, 2003
RESIDENTIAL
2004 RESIDENTIAL 2004
u C I ION 2 1�RO tii 1s11
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2.1 Owner of Record:
sos&
Na (print)
Contact Address Phone Number
2.2 Authorized Agent:
Contact Address " Phone Number
Name (print)
SECTION CON TRUCI'ION'
ER"
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
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 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)
EC C i4 Oftkt + f Mill $ATI(3N !NSUItANCE AFF iiA )UIDL C
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit
will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ yes ❑ no
l CFSE TITiV C3 1�
a
❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ ❑ woodstove
(energy report required) (energy report required) fireplace
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ demolition
(shed/garage) no. of windows_ doors_ (specify below): (specify below):
* If new construction, please complete the following:
Single Family: no. of bedrooms no. of baths
Two Family: no. of bedrooms unit 1 no. of baths unit 1
no. of bedrooms unit 2 no. of baths unit 2
❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other
Brief Description of Proposed Work: CE -fO F G ,1r T r,95
N O
�q 'SF
CTI(3N 6; ES IMATLD GCtiNS RUCT(ItY COSTS
Item Estimated Cost ($) to be completed by permit applicant
1 Rnilrlina
F.lertrirnl
i Phimhina
,I Merhnnirnl (HVAC')
5. Total = (1 + 2 + 3 + 4) * Estimated Total $
R 'VT ORI7�')'IIJN
a (to be c mpTeted whmn €lens tigenttre antra tar aRph for utidutg'pernnt)
.. m ss ® . a s®� � .��
(please print)
I, 1 A as Owner of the subject property hereby authorize
to act on my behalf, ' a 14krs elative to work authorized by this building permit application.
Signature of Ownei Date
SRCTI+ N 713fI'lif�lt�ER/A1:7THO)kIZ) I) AGENT U�CLARATI(J V
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.
S' ned u der the ains and nemaRies of perjury.
3
Signature of Owner/Authorized t Date
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