BP-2005-39517RESIDENTIAL
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1 Owner of Record:
C/
Name (print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address Phone Number
NO, 0/p -E I"OK"M WO,
P'3 V' TRUCT
Not Applicable 0
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor
License Number
Address
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor:
Not Applicable 0
Are you a Home Improvement Contractor subject to (780 CMR-6)? 0 yes 0
no
If no, go to the next section!
Arf, you claiming exemption from the requirement? 0 yes 0 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
4�0 Lac 6 L ) 64
Owners Name �prinfi ,
Sign, e
igning the above, the homeowner acknowledges that there will be no eligibilty to the Guaranty Fund
Lb
Date
1'3.4 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 ofbuildings
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 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 dwellint, 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 applyi nder thisse I below:
s
Signature:(ion
,
Your signature carries certain responsibilities, including but not necessarily limited to, general liability
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Rev. January 2005
I
RESIDENTIAL
L NOTIICE 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)
S
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: 0 yes 0
n
0
N
W�OF K, OPOSED
5-
0 new construction* 0 addition El alteration 0 repairs 0 chimney/ 0 woodstove
(energy report required) (energy report required) fireplace
0 deck 0 pool 0 accessory bldg. 0 replacement window/door 0 other 0 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
TwoFamily: no. of bedrooms unit 1 no. of baths unit I
no. of bedrooms unit 2 no. of baths unit 2
0 Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
13 Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify):
11 HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
0 Air conditioning - (separate unit)
El None of the above to be provided
11 Hot Water: Gas Electric Fuel Oil Other
Brief Description of Proposed Work:
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Item Estimated Cost to be completed by permit applicant ,
1. Building '34900.60
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total = (I + 2 + 3 +4) Estimated Total
(please print)
as Owner of the subject property hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
A
as Owner/Aijthorized Agent hereby declare that the statements and information
/911the foregoing application are true and accurate, to the best of my knowledge and belief.
VSigned under the pains and penalties of perjury.
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Signature of Owner/Authorized Agent Date
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RESIDENTIAL
f;
RESIDENTIAL
❑ FOUNDATION vIdLY
1. Date plan reviewed:
2. DENIED (see project review
worksheet):
3. HOLD
reason:
4. HOLD subject to Zoning Board of Appeals action:
Comments:
inspector's Signature:
Applicant i
Comments:
I Date:
M
Date:
Date:
Date:
Date:
Total Permit Fee: $ ((, n ® 0 � Less Application Fee: $ 25.00 I Remaining Balance: S ��., ® 6
TOTA1: FEES , 0 6 Gross Area - New Construction total sq. ft. /`/"Of /
Gross ArAa - Alteration total sq. ft._ f*fA . /
Permit 'issued To- 4,6 S - /0 n � Sz" "g S v 4/ n ea C, avc L. s `r e ,, t
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Rev. hvuary 2005
M-VLA%;1&-a'aV1V k-K& i, 1MVN-K&;TVNDA15LE & NUN-WHANSFERARLE
DATE RECEIVED
DARTMOUTH BUILDING DEPARTMENT43
400 Slocum Road, P.O. Box 79399 ff _
, . # 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: -�-;z
Ene gy Report:
Signature:
Date:
Fire Chicf:
Signature:
Date:
Board of:l:,aith:
Signature: .44
Z` v
`Date:
Conservation Cotnrn;ssion:
Signature:_
Date:
11141 .
Other:
Signature:
�
Date:
i
Description of work being performed:
Nl, aI3ER OF PLANS SUBMITTED: ( SITE PLAN SUBMITTED: ❑ yes ❑ no
1.2 Assessors Map & Lot Number: �
i Property Address:a ' e )QLkiMap Lot - C
Nearest Cross Street:
Subdivision Name: _ 1.3 Historical District ❑ yes ❑ no
To al La d�Area Sq. Ft.: Has application been submitted to the Historic Commission?
❑ yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54): L11 1.5 Sewage Disposal Svstem:
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