BP-17189R F.CTTIFI�TTT A T .
2000
RESIDENTIAL 12000
❑ FOUNDATION ONLY
d
1. Date plan reviewed:
2. 30 days to review period expires:
3. OK to issue date:
4. OKtoissue subject to requested submittals(see project review worksheet):
5 DENIED (see project review worksheet):
6. HOLD reason:
7. HOLD subject to Zoning Board of Appeals action:
R rnmmentc-
9. Inspector's Signature:
Applicant infopnAd of above
Date:
Date:
Date:
_Date:
e:
Total Permit Fee: $ Less Application Fee: $ 25.00 Remaining Balance: $ L _N
TOTAL Fh, c Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq' ft. _
Permit Issued To
e*
$25.00 APPLICATION FEE IS NON-REFUNDABLE & NON-TRAN51"ERASLIQ
, �..... y, DATE_ RECEIVEb
s, DARTMOUTH BUILDING DEPARTMENT `
='o 7-, 400 Slocum Road, P.O. Box 79399 �, 3 ti 05
Cz
Dartmouth, MA 02747
--.1.6 6�-` 508-999-0720 FAX 508-999-0738
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Zoning Review: Signature:
Date:
Energy Report: Signature:
Date: _
1 Fire Chief: Signature:
Date: _
Board of Health: Signature:
Date:_
Conservation Commission: Signature:
Date: t
Other: Signature:
Date:
Description of work being performed:
NUMBER OF PLANS SUBMITTED: SITE CLAN SUBMITTED: ❑ yes ❑ no
ff ,, ►�r`1.2 Assessors Plat & Lot Number:
1.1 Property Address: � S!Abtc l r, Plat
Nearest Cross Street: ,Y/Xi-es [ia P) AD
Subdivision Name: — 1.3 Historical District ❑ yes ❑ no
Has application been submitted to the Historic Commission?
Total Land Area Sq. Ft.:
❑ yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Private Well ❑ Municipal ❑ On Site Disposal System
Page 1 Rev. January 13, 2000
,,,,,a page d Rev. January 13, 2000 C:\bldg.fornns\Bldgapp.res.wpd F -- _
2000
RESIDENTIAL
t [,2.1Owner ofRecord:
L
Name (print)
Name (print)
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor
Address
r -Y
Telephone
ContactAddress
3.2 Registered Home Improvement Contractor:
Are you a Home Improvement Contractor subject to (780 CMR-6)? es ❑ no
If no, go to the next section.
Are you claiming exemption from the requirement? 0 yes If es, submit9-mthe
required affidavit!
I Company Name w
Address4
Si° gnature V Teleph - 05
�— R 'clutial Remodel Work n y
Not Applicable ❑
License Number
Expiration Date
Not Applicable ❑
2000
RESIDENTIAL
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)
7=
J,.
6111
�Phojn�eNumber 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
❑ new construction* ❑ addition
Phone Number (energy report required) (energy report required)
a.
❑ deck ❑ pool 1 ❑accessory bld
(shed/garage)
* If new construction, please complete the following:
Registration Number (if none, state "none")
ion Date t -41
3.3 For es t - 1
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) 72J-8598
f9v✓ners Name (pri - - --- -
tiigrature —_ � --�-
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 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 individua:
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.
g work for which a Building Permit is required shall be exempt from the provisions of this section; provides that if a Homeo vnsr
Exception: Any Homeowner performin
engages a person(s) for hire to do such w(,-:., 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.
i
If you are applying under this section sign below:
Signature:
Your sisnature carries certain responsibilities, including but not necessarily limited to, general liability
❑ alteration ❑ repairs
❑ replacement window/door
no. of windows_ doors
Single Family: no. of bedrooms no. of baths
❑ chimney/ s ove
fireplace
IQ-6fher ❑ demolition
(specify below): (specify below):
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 fiiel, natural gas, propane, electricity, other (specify):
❑ Air conditioning - (separate unit)
❑ None of the above to be provided Other
❑ Hot Water: Gas Electric Fuel Oil J
Brief Description of Proposed Work: �� � ,� Pe e---
- W-
q5- -'
Item Estimated Cost ($) to be completed by permit apt licant.
luildme
1ectrical
3. Plurrrbin(y
4. Mechanical (HVAC)__
5: Total = (1 + 2 + 3 + 4) * Estimated Total $ 02, yO c' a,
r _ /
(please print) ,,y -Z-L/, ' "_ /lip
1�- 4 �, C,as Owner of the subject property hereby authorize 1
to act my behalf, in all m �ters relative to work authorized by this building permit application.
0>f-mac,
R;u ture of Owner —
as Owncr/Authorized Agent hereby dec-are that the statements and infonnatton
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed underpe pains and penalties of perjury.
Si
Authorized Agent
Date
I)—') Rev. January 13. 2000
C:\bldg. forms\Bldeapp. res.wpd
Paee 3
Rev. January 13, 2000