BP-46327RESIDENTIAL
SECTION 2`- PROPERTY OWNERSHIP/AUTHORIZED
AGENT
2.1 Owner Record:
F�1 pp CC j
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Name (print)
Contact Address Phone Number
2 2 Authorized Agent:
Name (print)
Contact Address Phone Number
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor. A_ .. _
Not Applicable ❑
Licensed Construction Supervisor:
License Number.
Address: ` o ~'
Expiration Date: Q�
-5
Signature- &&r, .____ Telephone:. �� �/� (�
3.2 Registered Home Improvement Contractor: L' 1,.�
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ Yes ❑ No
If No, go to the next section!
Are you claming exemption from the requirements? ❑ Yes ❑ No
If Yes, submit the required affidavit!
Company Name:
Registration Number (if none, state "none"):
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Address:Lo, KBt h 1 t e ' L i/'
Signature: Telephone.
Expiration Date:' ; j
t l 1 1
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
❑ 1 am a Homeowner performing all the work myself.
Owners Name (print): r 1 . ",%L _4 c
Signature: 0,02z _. )�, ;' y �t ref
By signing 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
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
IN
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)
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 5DESCRIPTION OF PROPOSED WORK (Check all applicable)
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[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:
SECTION 6 - ESTIMATED CONSTRUCTION COST
Item
Estimated Cost ($) to be completed by permit applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=(1+2+3+4)
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SECTION 7A -OWNER,AUTHORIZATION
to be completed when owner's agent or contractor applies for building permit)
(Please Print)
la in a �tx��.� as Owner of the subject property hereby authorize
to act on my behalf, in allmatters relative to work authorized by this building permit application.
Signature of Owner �T
Date
SECTION 713-`OWNER/AUTHORIZED AGENT DECLARATION
I, 3, 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.
Signed under the pains and penalties of perjury.
Signature of Owner/Authorized Agent Date
SECTION 8 - INSPECTOR'S REVIEW/COMMENTS
1. Date plan reviewed:
2. DENIED (see project review worksheet):
3. HOLD
Reason:
4. HOLD subject to Zoning Board of Appeals action:
Comments:
Date:
Date:
Date:
Inspector's Signature:
Date:
SECTION 9 -APPLICANT NOTIFICATION
Applicant informed of above: Date: Time:
Comments:
Clerk:
SECTION 10 - OFFICE/INSPECTOR'S NOTES
Total Permit Fee: $'
Less Application Fee: $25.00
Other $ Amount $
Remaining Balance: $
TOTAL FEE: Gross Area - New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Permit Issued to:
SECTION 11 -ADDITIONAL COMMENTS/SKETCHES
❑ SPECIAL PERMIT (Per 750 CMR 111.13)��.
$25.00 APPLICATION FEE IS NON RE-FITNDABLE aX NO,��rftBLE�
.... ....
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DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road, P.O. Box 79399
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Dartmouth, MA 02747
Slv.;
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
THIS SECTION FOR OFFICIAL USE ONLY ✓ 1
RECEIVED BY;
BUILDING PERMIT NUMBER: -
DATE SENT FOR REVIEW;>"�"d':`"
DATE ISSUED:
O.K. TO ISSUE - SIGNATURE:
DATE:
Zoning District:
Proposed Use: Zone: ❑ C ❑ B ❑ A ❑ V Aquifer Zone:
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED:
h o
❑ Board of
❑, Board of ❑ Cons. ❑"Demo ❑ DPW
❑ Elec. ❑ Energy Report
Appeals
Health Commission Affidavit Card Sent: Cut Off Follow-up*
❑ Fire
❑ Gas ❑ Planning ❑Sewer Card ❑ Water Card ❑ Zoning ❑ Other
Chief
Cut Off Board Cut Off Cut Off
*REQUIRES INSPECTOR'S REVIEW BEFORE THE ISSUANCE OF A PERMIT.
DEPARTMENTAL APPROVAL
�
Zoning Review:
Signature:
Date:
Energy Report:
Signature:
Date:
Fire Chief:
Signature:
Date:
oard of Health:
Signature:ZQ&'4�gzzl-
Date:
Conservation Commission: Signature:
Date:
Other:
Signature:
Date:
Brief description of work being performed:
SECTION 1 - SITE INFORMATION
/
1.1 Property Address: /. !
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1.2 Assessors Map &Lot Number:
Nearest Cross Street:
Map Lot c-
Subdivision Name:
1.3 Historical District ❑ Yes ❑ No
Total Land Area Sq. Feet:
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
1.4 Water Supply (MGL c40 s54):
1.5 Sewage Disposal ;Syst�em
❑ Municipal ❑'Private Well
❑ Municipal On Site Disposal System
El CONSTRUCTION PLANS ® SITE PLAN ® ENERGY REPORT